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PERMffCEE NAME/ADDRESS pne(ude Faci(iry Nmne/(ocnrion i/Di$erenr)
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<br />ADDRESS !1[4r,'i 1.2'1 ~J;; ^':`~ -^v+EV 7?
<br />9107 '"~S'' - ~eL ;-To^_~°_
<br />FACILfTY
<br />LOCATION
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<br />NATONAL POLLIJTAM DISCHARGE ELIMINATION SYSTEM MPDES)
<br />DISCHARGE MONITORING REPORT (DMR~
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM " ' ~ ! TO " ' ~'
<br />(2641) (tt-t31 (ta15) Q&Yr1 (2S~4W (36311
<br />Forth Approved.
<br />., r , ,~ ~ OMB No. 2040-0004
<br />Approval expires 05-31-OS
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<br />NOTE: Read InsVUCtions bef comp ling this forth.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-87) 38-45) (48.53) (54-B1) EX OF TYPE
<br />~3n AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~
<br />~ 6&70
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERDFY UNDER PENALTY OF I
<br />AM FAMILIAR WITH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMrRED HERE NAIIY E%AMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
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<br />:I,~.r is rd Mllls INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY gESPON
<br />THE INFORMATION, I BELIEVE THE SUBMITTED IN ;
<br />SBLE FOR OBTAINING
<br />FORMATION IS TRUE,
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<br />~nvironrnental 2':anDger
<br />ACCURATE AND COMPLETE. I AM AWARE THAT TH
<br />PENALTIES FOR SUBMrITING FALSE INFORMATIO
<br />ERE ARE SIGNIFICANT
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<br />INCLUDING THE // L~~!/~
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<br />POSSIBILT' OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 41001 AND 33 U.S.C.
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence ell attachments here)
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<br />EPA Form 3320-7 (OS~S) Previous editions may not be used. ~ (REPLACES EPA FORM 7~0 WHICH MAY NOT BE USED.) ,I n T ~ ~ / ~ ~ O n) ~-~ ~ ~ II PAGE ~ OF
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