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PERMITfEE NAME/' ~-1gE5S (L.d:4frmryNr'lncuar pDt5loev)
<br />NAME ..~r L. vcL .. :'. .':, :i! !....
<br />ADDRESS I. .1 :.,1 ~. ':' [..;
<br />FACILITY ~~ ~'-,~ ,-"
<br />LOCATION -i
<br />NATIONAL POLLUTAF ~CHMGE ELIMINATION 9YBTEM (NPDESI Form A red.
<br />DISCHARr ONITORINO REPORT OMR1 (~MB N. X40-0004 ~.
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<br />PERMIT NUMBER DIBCHAIIGE MUMBFA ~
<br />`' ! ~ I' L MONITORING PERIOD " : 'i l- '
<br />YEAR MO DAY YEAR MO DAY
<br />,. FROM y7 f,7 ::-;1 TO 97 C9 "~ r:n Ir. .., ::rn... .
<br />!16711 l71-231 (1I-161 !2627/ I1B-191 130-311 ~~~ NOTE: Reid Irutrualoru bef«e-eemlpletlnp Ehie form.
<br />PARAMETER l3 Ord Onlyl QUANTITY OR LOADING l4 Ord Onlyl QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE
<br /> !16531 !54571 38-151 !0653 154-5I1 OF
<br />l31-371 EX
<br />ANALYSIB TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS l57-Ba! !54581 15&701
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<br />NAME/i1TLE PRINCIPAL EXECUTIVE OFFICER 1 CERTIFY UNDER PENALTY of
<br />AM FAMILIAA WITH THE INFO uw TNAT I NAVE PERSONAUr ExAMINED AND
<br />RMATION SUBMITTED HERDN; AND BASED ON ~' TELEPHONE DATE
<br /> MY INQUIRY OF TNOSE IMDIWDUAlS IMMEDIATELY RESPONSIBLE FOR '
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<br /> OBTAINING THE INF011MATION, 1 BELEVE THE SUBMITTED INFORMATON IS :
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<br />/ TRUE. ACCUMTE AND COMRETE. I AM AWARE THAT TNERE ME
<br />SIGNIFICANT PENALTIES FOR BUBMITTNG FALSE INFORMATION
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<br />i. I v'•'• ! I 1 THE POSSIBILITY OF RNE AND IMPWSONMENT. BEE tB U.B.C. 1 1001 AND B]
<br />810NATURE OF PIIINCIPAL EXECUTNE : r
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<br /> U.B.C. 1 t 7tB. /MnreW uMr e5Fr mroro. m.r irAd~ fvws No ro FIO,p00
<br />TYPED OR PRINTED r,snrnuNwn htp'Imnw,r or btw.rlemenlYMWS y.ra/ OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a// sTFechmin/a here/
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<br />EPA"Foim 3320=1' 108.951' ~ PrevtouB~editions rney be lined. ~ (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.1 PAGE OF
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