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PERMffTEE NAME/ADDRESS pnclude Facility NmndLocatlon ijO fferenq
<br />NAME CY?4!Ii Y1°^5 ~~:,-• ...1e( °lnr,
<br />ADDRESSlLrNE'i L~?',} ~p~T"'-~ ~ c•••ah~y pr
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<br />FACILfTY _ i
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<br />NATIONAL POLLIfTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR;
<br />(1-161 (1 ~- 9)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM " ' ~~' ~ TO '' 1 1
<br />[2o-z11 (72-731 Q475) (26-111 (78-791 (3631)
<br />Form Approved.
<br />f ~ „ OMB No. 2040-0004
<br />Approval expires OS-31-88
<br />(cncr "q)
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<br />PARAMETER (06.53) (54.61) (3Bd5 (46-53) (54-61) p( OF TYPE
<br />(32-3n AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF L
<br />AM FAMIDAR WRH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%M7INED AND
<br />IN; AND BASED ON MV -
<br />i TELEPHONE DATE
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<br />d INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE, '
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<br />' AOOURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING 1 AM AWARE THAT THERE ARE SIGNIFlGAHr
<br />FALSE INFORMATION
<br />INCLUDING THE
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<br />18 U.S.C. 91001
<br />ND 33 U.S.C.
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<br />NUMBER
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<br />MO
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<br />UUMMtNTS AND EXPLANAI IUN UY MlY VIULA I IUNJ (KBra/enCa all a[raCnmen[S nereJ
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<br />EPA Form 3320.7 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NO7 BE USED.) n n T p n ~ 7 1 p 1t 1 ~- t S ~ ri PAGE ~ OF
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