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PERMITTEE NAME/ADDRESS !!nclude Facility' Name/Lacauon fDiBerenr)
<br />NAME F'iC9fT~IIbF ki1CCE,SIrtC, LLC
<br />ADDRESS E Mx; L N MIN E
<br />111 FREyTrCCL 1bIY~
<br />c ~On•+f.7ILLt IN 47711
<br />FACILITY
<br />LOCATIONy F..i L C t C C C l C 51
<br />Filly: ril icti,Y, CAA6CFh
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCRARGE MONITORING REPORT (DMR;
<br />(2 1fi1 !t] 9)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO D - ;: YEAR MO DAY
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<br />(20-2i1 (22-2J) IPJ~1 (P6~Y)1 (P6~d9) (JOJ1)
<br />Form Approvetl.
<br />r I t: C F+ OMB No. 2040-0004
<br />` Approval expires OS-3f-98 ~
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<br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
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<br />INQUIRY OF THOSE INDIVIDUAL
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<br />ON MY
<br />S IMMEDIATELY RESPONSIBLE FOP OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
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<br /> ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT ~ ~.~
<br /> PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING THE
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<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 5 1001 AND 33 U.S.C.
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<br />EPA Form 3320.7 (08-95) Previous edluons may nol be used. (REPLACES EPA FORM T-40 WHICN MAY NOT BE USED.) C G 013 / 0 U C ] ] 1-16 s` C PAGE ] OF
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