PERMITTEE NAME/ADDRESS (T,.idr Fsd~ryNa/lau,m UDI$ m1) NATIONAL POLLUTANT DISCHARGE DJMINATON SYSTEM /NPDESI
<br />NAME a' [/ ~ W'- r Q DISCHARGE MONITORING REPORT IOMRI
<br /> ( I7-16I 17-191
<br />ADDRESS n~a ::LS !I"F' C'1000 90 009 A
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<br />--PERMIT NUMBER DISCHARGE NUMBER
<br />4~`!-111 ~-f..~. ~Cr a?f'r-~y}~y1 Cv fjOL37
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<br />FACILITY MONITORING PERIOD
<br />' YEAR MO DAY YEAR MO DAY
<br />LOCATION
<br />S.M CUd~'f' L-Q HLD 91 FROM TO
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<br />Form Approved.
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS l67.6a1 /66681 /69-701
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERTIFr UNDER PENALTY. of
<br />AM FAMILIAR WITH THE INFO uw rNAr I NAVE PERSONALLr ExAMINm AND
<br />RMATION SUBMITTED HERDN
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<br />MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPON518LE FOR
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<br />I BELIEVE THE sUSM17TED INFORMATION IS
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<br />TRUE, ACCURATE .AND COM0.ETE. 1 AM AWARE THAT THERE ME !
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<br />THE POSSIBRJTY Of FNE AND IMPRISONMENT. SEE IB U.S.C.f 1001 AND 77
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<br />TYPED OR PRINTED nW Or nrrhllnr uneWlaulnNnr olMMwn enonNi rW6heal OFFlt:ER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
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<br />EPA Form 3320-1 108-95) Previous aditione may be used. IREPLACEb EPA FORM T-40 WHICH MAY NOT BE USED.) ,7 ~ ~ / , ~ ./ / / :~ 1 ~ _ 17 ~ 1 PAGE rOF
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