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<br />PERMITTEE NAMEIADDRESS (Include Faciliry NmnrJtocadon lJDi$erenQ
<br />NAME
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<br />ADDRESSN,)RTH TNO%E':,JN C;tt'~K t"INF.S
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<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHARGE EDMINATION SYSTEM (NPDES) FolTn Approved.
<br />DISCHARGE MONITORING REPORT (OMRJ OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE,NUMBER F 1' r i R A L P C t' ! '~
<br />MONI PERIOD '~^: C07 COdBINED DSCHP.G
<br />Y ' ~ MO DAY. YEAR MO DA
<br />FROM 1 TO UO 12 ~ :~ 'u) DISCH-RGE (^) ~'+~`
<br />"NOTE: Read Instructitins~beTore completing this form.
<br /> QUANTITY OR LOADIN QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />;,FFLU°r,T GROSS YALU j0l4REM~Nr ~;~`> 4:tYd ...'s ~~
<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICerory under penalty of law that s ptllhantand all altachmeMS were TELEPHONE DATE
<br /> prepared under my direction or a rylalOn ro accordance with a system designed
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<br />~ ro assure that qualified personnel ropedy gather and evaluate the inormation
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<br />' submMed. Based on my inquiry theperson or persons who manage the rystem, ,
<br />~ or those persona directly respon bleidr gathering the information, the information
<br />'rr,/S t DE~ submihetl is, to the bast of my knowledge end belief, true. accurate, antl wmplete. ~IGNATURE OF PRINCIPAL E%ECUTIVE ~ Z ' `~/01 ~ ~
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<br />TYPED OR PRINTED 1 em aware that rhere ere signtlkanl penalties br subrtntting false information,
<br />inciutlln the osslbih "fine afid im dsonment ror knowin Notations. A
<br />OFFICER OR AUTHORRED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a//attachments pare)
<br />P`:H"•ITTES `:US't ?~UT1YY ~1'.;b f^ !?Ati~ r•Rif%4 TC CO•fb1NING UISC`1ARGF:S-PAii1 i.A.4, PC. jY. MONTH L'! SAMPLING FOn
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<br />~. o..e-S.& e -~C_ ~. 0.01.5-LOD0717-123 1
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