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PERMITTEE NAME/ADDRESS (/nclude Facility Nwndfocadon tfDifferenf)
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<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR~
<br />(2-161 rf ]- 9)
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<br /> PERMIT NUMBER DISCHARGE NUMBER
<br /> MONITORING PERIOD
<br /> YEAR MO DAY YEAR MO DAY
<br />FROM '~ T l'J ~ 1 TO .~'1 ^ c Z ^
<br />(2P2/) RZ.z3/ (24151 (~6-t]) f1B-t D1 (3x311
<br />Form Approved.
<br />OMB No. 2040-0004
<br />~~' ~^' Approval expires OS31-fd8
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTFY UNDER PENALTY OF L
<br />AM FAMILIAR WRH THE INFORM AW THAT I HAVE PERSONALLY ExAMINED AND
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDMDUAL ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING ,
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<br />EPA Form 3320-1 (OB-95) Previous editions mey riot be used. ~(REPLACES~EPA FORM T40 WHICH MAY NOT 9E USED:) - L " ' ~- " ~ ~ ' '~ ' ' ~ ~ - ' PAGE - ~ "OF
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