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FERMITTEE NAME/~SS l1.dr6 Fr,0yNr'fau:w llDrpsnp
<br />NAME
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<br />ADDRESS i,;li.;.'.,Yf, !?.'I !'
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<br />FACILITY
<br />LOGTION - , /
<br />`It. ~- ,. I f~IP •n ~~~•
<br />NATIONAL POLLUTMT HMOE ELMINATON 9Y9TEM INPDESI
<br />DISCHAR ITORINO REPORT lOMRI
<br />7-16 17-191
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<br />PERMIT NUMBER DI9CHMGE NUMBFA
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM ~ ~} t i) D 1 TD Q f1 l i 31
<br />!76711 /17-731 171-75I 176-771 118-79I !36311
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<br />Form Ap ed.
<br />Approve Iree'OS-31-98
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<br />NOTE: Read In~trugTlone balora coTnpletlnp thle Corm.
<br />PARAMETER !3 6rd Onlyl QUANTITY OR LOADING !I Grd Ontyl QUANTITY OR CONCENTRATION NO FREQUENCY gAMPLE
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<br />l3I-371 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX
<br />R7-e]I MKYSIS TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY UNDER PENALTY of
<br />MIDM N11TH THE INFO uw THAT I HAVE PERSONALLY ExAMINED MD ~
<br />RMATION SUBMITTED HEREIN: MD eA9E0 ON TELEPHONE DATE
<br /> MY INQUIRY OF TH09E IMDIVIDUAL9 IMMEDIATELY RESPONABLE FOR
<br />OBTNNINO THE INr011MATON, I BFLEVE THE SUBMITTED INFORMATON IS / ~
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<br />TRUE, ACCUMTE AND COMPLETE I /JA AWME THAT THERE ME ~`
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<br /> SIGNIRCANT PENALTIES FOR 9UBMITTINO FALSE INF011MATIOM
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<br />THE P0991RI11TY OF FNE MD IMPN90NMENT. SEE 1B U.S.C. 1 1001 MD ]]
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<br />~BIOJIATURE OF PRINCIPAL EXECUTNE ~ ~ ~ II )~
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<br />Wn:r,.ain:.n YrEa,lAemlvrrWb,wwnemanNartl bY..r+l ' pFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRelerence e!! ettschments hate)
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<br />5'r'iTL;:.4:.L:, ~GLT!IP. LI!'?~ APP].IFS UNLY IF C= 1U-Y'd, ,4-Hfl PfiEC?F PYP.4'" I`. CS.'.I'"°. ii. ~, -t.',I,', ,. ;`-t:.):.•,:~r ~,•v
<br />:ll 7:.-. .. T`'Gt! L;vi'C[, dIL1. NOT !1 F. APPLIED TD !iF.PUR^ED f1EASURE'MEtITS--SFF. T.9.1 i, ,,, ~". ... .;I~ ~~i h.
<br />EPA Form 320=1 108-951 'Previous editions }nay be us ~ A. ~ (REPLACES EPA FORM T-0O WHICH MAY NOT BE USED.) PAGE OF
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