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<br />NAME p.i•;A)~~Y_CS~A.I.S~ LYSLCLAIIINEI~---
<br />ADDRESS ~ -~~~~SIr F... _. ~,~;~~.:'i.
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<br />LOCATION__ ~ _-~-- --r.;..l::r:iA:=~.__
<br />Ai?t+: DENNIS ;STEY~HSON PRE DEN-
<br />NATIONAL POLLUTANT SCMARGE ELIMINATION SYSTEM (NPDES/
<br />D{SCHAR NITORINO REPORT /DAfR/
<br />(1-16 (17-19/
<br />PERMIT NUMSEA ~•IIO DISCHARGE NUMBER
<br />,~ : a =m I~
<br />~' `:i ., MONITORING PERIOD
<br />=:FROM YEAR MO DAY ~ .YEAR MO DAY
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<br />/161/1 (11-13/ (TI-SS/ (1617) /18-I9) 130.31)
<br />F - FINAL ,
<br />ACUTE fiET TESTING FOR_OUTFALL
<br />--- - -
<br />[lS~NOR (5U8R `~AC)~ ::INTHS
<br />NOTE: Read Instruetlons before eompleting this lorm.
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<br />/6r-681 16970/
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<br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER' I CERTI
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<br />FAMILIAR WRH THE INFORMATION SUBMITT ERSONALLY E
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<br />^ THE POSSIBILITY OF FINE AHD IMPRISONMENT: SEE 19 U.S.C. 4 1001 AND
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<br />1: 1979
<br />/A•nv/aa •Me. +Aw +rarma mar Mrluea !nm uP m 719
<br />aW SIGNATURE OF PRINCIPAL EX UTIVE 'SAS
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<br />rnesmadwrnlrlmp'bawmrnr o/esrwrn6monrA+ane !truer./ OFFICER OR AUTHORIZED AGENT NUMBER - 'YEAR MO OAY
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS IReJenncrrRafrarhmrnv hen) ~ i.
<br />SrE PART I.3~ GF PERI'7IT FOAr.DEi,AiLS OF TEST PROCEGUfiE. REPORT RESULTS OF IIIC TEST--AS "Y~ININU"' ANG 50:;
<br />tlORTALITY TE52 AS "CA%ICU:1".~AND~;i1TTACH ACUTE TOXICITY TEST R£PORT FORM. T0. Dt:R.;.r `COPIES OF ALL INt'Oil7ATIci;.
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