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PERMITTEE NAME/ADDRESS (in de I /n,J NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDRS) FormApMwd
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<br /> -- �,/ MONITORING PERIOD I+ •� I _ _ c d -
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<br /> (3 Card Only) QUANTITY IOR LOADING (4 Card Only J� OUAL_ITY OR CONCENTRATION
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<br /> >< _ _ EX ANALYSIS `TYPE
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<br /> NAM! TITLE PRIN IPAL'EXECUTIVE OFFICER 1 CERTIFY UNDER PENALTY OF LAw XAT I NAPE PERSONALLY EXAMINED -- --3 -, TELEPHONE' D A T♦E
<br /> ANO AM FAMILrAR WITX THE INFORMA ION SUBMITTED NEflCIN AND
<br /> BASED •. VI tiC Y. Y _� _
<br /> ON MY INWIRY OF THOSE INQVIDU LS IMMEDIATELY RESPONSIBLE FOR
<br /> OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION ✓ C - ^_ •j ` - �? 1 _ L
<br /> R TRUE ACCURATE AND COMPLETE n AM AWARE THAT THERE ARE SIG'
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING --T "' -" �` I yt•
<br /> yf faw TXE POSSIBILITY OF "RE AND IMPRISONMENT SEE IS USC 1 1001 AND
<br /> //, /�/Ir(7•-C/ rD/ OIL/frG-� P 'SIGNATURE OF PRINCIPAL EXECUTIVE -
<br /> 33USC 113.9 lPrnalfR. anal, 1Arr IIaIYNF erM mrlWr /mr. uP la rI11,IXMl
<br /> TYPED OR PRINTED anan.maMlmum rmpnurnnl✓nr a/Arruwn RmnnrA.MnilA�n..1 , 'OFFICER OR'AUTHORI2ED AGENT•. 'NUMBER YEAR MO DAY
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<br /> COMMENT AND EXPLANATION OF ANY,VIOLATIONS (Re/erenee all almrhmenl] here) ; C C .J -J• h j ='S_ 1 f- ,`; - _
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<br /> EPA Form�,V. I0.79)PREVIOUS EDITION UNTIL SUPPLY IBEXHAUSTEDTOBESED (REPLACM EPA FORM - O WHICH MAY NOT BE USED.) P�L
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