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PERMITTEE HAM' ~DRE55 pd~.f~myA'..rF~.ud,dDlpc..W
<br />NAME i. t.-.- ~ '~•rr.v .,.^'I n:i1 i-.c.
<br />ADDRESS':., Vii, .: ,; ': I ,..
<br />FACILITY
<br />LOGTION
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<br />e. ! V: 1' ~i i
<br />NATIONK POLLUT/ ' ~ISCHMOF ELIMINATION SYSTEM /NPOES) Form n -roved.
<br />DISCHA! MONITORING REPORT OMRI ~ OMB !040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBEA (~ l ~ ~' 1 ~~ 1 ~• '
<br />MONITORING PERIOD k r ±; r 1:
<br />YEAR MO DAY YEAR MO DAV
<br />FROM 77 l7 Ui TQ ;7 C9 :~ ;, ;; I; •• .. ;.. ,i:~. ,.I ~>f-~ :.: .:
<br />(76171 177-731 !1I-Y5I 116(71 (IS-YS/ /36371 NOTE: Raed Imtructlone belora "dompbtlNp thu form.
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<br />PARAMETER !3 0.rd Onlyl QUANTRY OR LOADING l4 Qrd Ontyl QUANTITY OR CONCENTRATION ND FREQUENCY
<br />SAMPLE
<br /> /6531 (5L57 138-/5 (1653 /5L871
<br />EX DF
<br />(91-371 ANKras TYPE
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<br />NAME/TI7LE PRINCIPAL EXECUTIVE OFFICER I cERTIFr uxOER PEMKTr of
<br />AM FAMIUAA NM1TH THE INFO Iww rHAT I NAVE PERSONALLr E%AMINED ANO
<br />RMATION SUBMITTED HERON; AND BASED ON ~ TELEPHONE DATE
<br /> MY INQUIRY OF THOSE IMDINDUK9 IMMEDIATELY RESPON9BLE fOR .~+ ..
<br />~ ~
<br /> OBTNNINO THE INFORMATION, 1 BFUEVE THE SUBMITTED INFORMATION IS '
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<br />' ~ TRUE, ACCUMTE AND COM0.ETE. I AM AWARE THAT TNERE ME
<br />INCLUDING
<br />LONIFICAMT PFNKTIEa F011 BUBMITTINO FKSE INFORMATION i '
<br />I ~ ! , I ~ i (
<br />: ~ .. . ~ THE POBSIBIUTY OF NNE AND IMPNSONMFNT. SFE IB U.S.C. E 1007 AND 7] SIONANRE OF PRIN
<br />IPAL EXECUTIVE ~ ~ _
<br /> U.S.C. E 1710. /AYWtl.. Mtlr drAr F6Nb. nrY Mch.W M. Iq ro F IO,OOD C
<br />TYPED OR PRINTED aM v+.rain.Fn iAa+l.aynrNa Mr.wnamwels rM6YwA1 OFRCER OR AUTHORIZED AOEN7 CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Raf~rsncs a//ettechmsnrs nerel
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<br />EPA' Form 3320-1.108.961 ~Pravidue'edition5'may be Eieed. - ~ (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 PAGE OF
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