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<br />FACILITY
<br />LOCATION
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<br />MATIONK POLLVTAN- <CHAAOE ELIMINATION 9veTFAr /NPDES) FOFm AF ' Ved.
<br />DISCHAR( DNITORINO REPORT OMR1 _
<br />1-le. J7-I9 : r r - : ~ ~ OMB N. 40-0004
<br />' Approve) expiiee OS-31-98
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<br />PERMIT NUMBER DISCHAROENUMBER (~ ~~ ~ ~ ~ `) -
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<br />MONITORING PERIOD f' 1 F C
<br />YEAR MO DAY YEAR MO DAV
<br />FROM ',7 V.1 ir' TO S7 l: 7] ^:;. ,~.. ,. ~. .., ~~i~ :..~~.
<br />1167/1 l77-73I !74751 176171 178-791 !36971 - NOTE: RnA InetruLtiiont bilw eompletinp~thb lorm.
<br />PARAMETER !3 Grd Only) QUANTITY OR LOADING !~ Grd On/yl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
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<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFO uW THAT I NAVE PERSONALLr ExAMINEO AND
<br />RMATION SUBMITTED HEREIN
<br />AND BASED ON % TELEPHONE DATE
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<br /> My INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON518LE FOR
<br /> OBTNNING THE INFORMATION, I BEVEVE THE SUBMITTED INFORMATION IB
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<br />SIGNIFICANT PEMALTIF9 FOR SUBMITTING FALSE INFORMATION
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<br />THE POSSIBILITY OF RNE AND
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<br />1 610NATURE OF PIIINCIPAL EIfECUTNE " +
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<br />EPA: Foirn 3320-T 108-961 ~ Previous~editidni mey be used. ' ' (REPLACES EPA FORM T30 WHICH MAV NOT BE USED.I PAGE OF
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