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PERMRTEE NAME/ADDRESS (Inclde Faciliry Name/Location ijOifferen,)
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<br />NATIONAL POLLIfTANT DISCHARGE ELIMINATION SYSTEM (NPOES) FOmI Approved.
<br />DISCHARGE MONITORING REPORT (OMR{ OMB No. 2040-0004
<br />(2-161 (f7. g1 F'I hL,i
<br />L ~ ~ f (` J E F . t } Approval expires 05-31-96
<br />PERMIT NUMBER DISCHARGE NUMBER F- f I r P i L F L] a', •,
<br />MONITORING PERIOD •^ T F i C L f F F 7 F P I I I I T C :' ~~
<br />YEAR MO DAV YEAR MO DAY __ )'.
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<br />(x230 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~
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<br />NAMERITLE PRINCIPAL FXECUfIYE OFFICER I CERTI
<br />AM FAM FY UNDER'PENALTV OF
<br />ILIAR WlRf THE INFOAM UW THAT I HAVE PERSO
<br />ATION SUBMITTED HEAE NALLY EXAMINED AND
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<br />AND BASED ON NY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDMDUAL ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
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<br />ACCUR FORMATION, I BELIEVE
<br />ATE AND COMPLETE THE SUBMITTED INFORMATION IS TRUE,
<br />I AM AWARE THAT THERE ARE SIGNIFICANT
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<br />. SIGNATURE OF PRINCIPAL E%ECLJTIYE
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />rtl'LtiI "sCT° (fiC CFICFI6E TFEAIrT) IF TIC CFILF.1t,F C'_'EL--SEt ,/. CIL L GhFFLE - 7.t.1.C, FC. r.. ,F7FIY
<br />~YF'LItiG INSIIiuCTICA~-I.C.C, E'G. 5.
<br />EPA Forth 3320.1 (OB-85) Previous editions may not be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) PAGE OF
<br />CCC17/79C77E-I`_~E I
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