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PERMITTEE NAME/~ ^'1REBS p~I. FsWryNawJFecauw I/Dlp..mp <br />NAME `,::. ~ 41. ~._~.;i~.'.~ n ~L L.. . <br />ADDRESS t-.;,-„r .,i:. ,~ <br />-, i .:.t .. I: 1 , .. i 1::.. I I <br />FACILITY <br />LOCATION <br />.I ' - I. <br />NATIONM POLLUTAN- "RCHMOE EIJMINATION SYSTEM INPDESI Form Ar ~ved. <br />DISCHARI ONITORINO REPORTPORT D~ _ .OMB N. 40-0004 <br />~~ ~ ~ ' 1 ~~ : ~ " 'I p n '+ F (; r ,i i,. ~ ,~ j ~ ~ ~~ Approvei expires OS-31-98 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD ° ~ ii ~ ~~ <br />YEAR MO DAV YEAR MO DAV <br />FROM '17 !i: ;,i TO i7 ~.' :1 .'.~:}•'.~ I~.~'.. i~. .:I ,>< ~.. <br />!20211 lZ2-131 171761 116-171 (18-19/ !3631/ NOTE: ~Resd In~intctlans belori eomlplatlnp thin form. <br />PARAMETER !3 Grd OnlYl QUANTITY OR LOADING !1 Grd Ontyl QUANTITY OR CONCENTRATION ND FREOUENOY SAMPLE <br /> !16531 !51.51 (38.151 !1653 !5/-57I DF <br />l37-371 EX <br />ANMras TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS Is7~as! 151-551 !56701 <br />' i .. n ~. i ~ .... ... SAMPLE ( ~ <br />:: j +i :7 : r; (~ ri t, <br />4 •~ • ~ ~ • .. . <br /> MEASUREMENT . <br />. 1::, a~ <br /> <br />•.. ..: I, _ :, ,. <br />~ ~ PERMIT :.:.; <br />~: ....,~.~::: ~~ <br />~ ~ <br />, ~ Y <br />.. <br />~ <br />I• ::_1 <br />a:)~Y,,~..:i. <br />:.aa:?. <br />~ ...... <br /> <br />S <br />,. <br />. <br /> <br /> <br /><, <br />, <br />' REQUIREMENT . <br />~ <br />~ ~ ~ .. <br />.. .. <br />.:}~.~.'; ~. <br />: ~~.i.Il. : ,n. <br />. r..'-II <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ ~~ <br /> REQUIREMENT ~~ ~ ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ . <br /> ~REOUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> :REQUIREMENT ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERM17 <br /> REQUIREMENT ~ ~ ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cERnFr uxDER PENALTY of <br />AM FAMILIM WITN THE INFO LAw TNAT I NAVE PERSONALLr ExAMINED AND <br />RMATION SUBMITTED HEREIN; AND BASED ON ~' <br />i TELEPHONE DATE <br /> MY INQUIRY OF THOSE IXDINOUALS IMMEDIATELY RESPONSIBLE FOR 1 ) <br />~ <br /> OBTNNING THE INFORMATION, I BEl1FVE THE SUBMITTED INFORMATION IB •~.,YJ r ~: ,'k%' ~~1 = --"' <br /> <br />~~ TRUE. ACCUMTE MID COMPLETE. I AM AWARE THAT THERE ME <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUOIMG ~ <br />' <br />. <br />~ <br />I ~' , ~1 ~ ,r <br />%iI~ . I I = - 1 <br />,~ ~ THEPOSSIBWTY OF flNE AND IMPNSONMENT. BEE to U.5.0.Et001 AND 7] BI <br />ATURE OF PRINGPAL EXECUTNE : - : <br /> u.s.c. 1 1718. lh.Wdr. I/I,/Y dwar mnm. nI.Y bcA.d. rvw. w ro t ID,DW Q AREA <br />TYPED fM PRINTED AMWIIII.%I,YII inFrlaorlrrw,t orbrwArlammBIFAM 5Ywa/ OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (/fe/erlrnce ee effsc/tmsnfs Alre/ <br />. .... ..... ... ..i i.f i,:, _i;.l: ...•i'L1i;.i ,,~!iLY .. G= .'I-°:F c~:'.... ?7, 1°.CIF VE'i'$ r~ Vii. i. !'.'t ... c ..-u l'. .!i I'. ..1 <br />- ..,.. ....,, i... ;'. .. ~1. i. ,t~~i .._ +i~i'~_.~!) fIt i!1'. I'~.1'l'.ii ._ 691;„p.NCt~'[`__~_°E. :. I..! f, .'I: 4 .. [I i. .. <br />r <br />EPA-FI»m 3320=1' 108-961 ~ Previode'editidne mey b'e used. IREPLACFS EPA FORM T-40 WHICH MAY NOT BE UbED.I PAGE OF <br />.' <br />