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PERMITTEE NAME/ADDRESS (include Facitiq•NamelLocaHOn ijDijferen()
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<br />FACILITY'rAND JUNCTION! CU B1SUb
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES)
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />t't'Ldr:;;T GHOSS V,4LUL REQUIREMENT Y +~
<br />NAME/TITLE PRINCIPAL IXECUTIVE OFFICER I Cerny under penalty of law mat this document and all attachments wire TELEPHONE DATE
<br /> prepared under my d~reaion or supervision In accordance with asystem designed ,
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<br />~` submitted is , to the best W my knowledge antl behel, true, accurate, end complete. SIGNATURE OF PRINCIPAL E%ECUTIVE y zW ~
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<br />TYPED OR PRINTED I am aware that there are signHlcant penalties for submming lelsa Information,
<br />includin Iha ssibili of fine antl im risonment for knowin violahorvs. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />r td':I T_TE:: ^I:I:iT N7^If'Y a.'-U JU DAYS P'?IJ3 TJ COCB[NI N; DISC;IA a;:ES-PA. :1 ~. d.'l, ;'J IV. MONTRLZ SA:9/LI,r `I FUG I
<br />1''i, t'LJM .. J::v •ILLUYe:li^Uh:NG PERIJD~ 7'' LT^v ACCE`°S: AiTrl^y tiTATS.'1FAT 'i0 'IMF.• 'J ETt'CTION LIMI:i-$6E I.F.Q.
<br />I=PA Form 33 -1 ( ~ ~) previous e i Ion m y e I(S~t}.' ~ • " 1 -` '~ ''' a .. i'., . . , ~ t ~ L r ., L+ u n i HIS 1~ A ~-PART F(KR~vY ~b,6~' ~ ' OF
<br />_ 00133/000717-1233 1
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