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PERMITTEE NAME/ADDRESS (InrAdrirWy NaWlawla IJD~ir•nx)
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<br />ADDRESS .'I:i '.J )., ..'.. ~~[l.~l'.., .. -.-.
<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM lNPOE$l
<br />DISCHARGE MONITORING REPORT lOMRI
<br />17-161 Ill-I91
<br />PERMIT NUMBER DISCHARGE NUMBEfl
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAY
<br />FROM '1 t TO '~~ " U `~
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<br />Form Approved.
<br />• .• ~ r~OM!}No: 2040-0004
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<br />J;. ,.I, ,~ 1: ;~ r Approval expirae.05-31-98
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<br />NAME/TITLE PRINCIPAL E%ECUTR/E OFFlCER I CERTI
<br />AM FA FY UNDER PENKTY OF LAW THAT I HAVE PERSONALLY E%AMINED MID
<br />MILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON TELEPHONE DATE
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<br />~iicha rd ~Y:Ifls MV INQUIRY OF THOSE INDINDUALS IMMEOIATELV RESPONS
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<br /> THE POSSIBILITY OF RNE AND IMPNSONMFNT. SEE 28 U.S.C. 1 2001 AND 33 SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> U.S.C. E tJta. lPrWeY• utlr e1•w .suns nl•Y h=N.J• rn•a .q ro J 10,000 AREA
<br />TYPED OR PRINTED wo.rlAYinun blAda•wlnr•IMw••n sm•nNa sw 6Y•sa/ OFFICER OR Al/THORRED AGENT CODE NUMBER YEAR MO DAV
<br />COMMENTS AND E%PLANATION OF ANY VIOLATIONS (Rderenea ell ettaehmants hare)
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<br />EPA Form 3320-1 108-951 Previous editions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 ~ ~ , ~ „ n , PAGE OF
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