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rCnNll lec nwNGwYDRE55(Intiudf NATIONAL POLLUTANT DIBGHARG MINATI TEM( FO VBC~ •^r•~ Ii). _C NIT~REPL/R) ~ ~ ~ _ ADDr.ESS~iv5------------ CGGd7UU1~: UU~t 4 FC:~L u AIJf::JFF TO 4fi1 ~ ~"p °iE+"na°~ p J ' ~ ~ ' - ~ ~ ' ` ~ y ~ 7 i 7 ? .v C .•-. c PERMIT NUMBER ¢ DISCHARGE NUMBEfk j ; ;. , . ~ .~ ~ x SUnEfl' r ~' l .CO Lj 44 j~.N.,-~ ~ C v r _. p ,. V J.[SW .: - ~ `^ ~ n '' `: MONlTO81NG'PEHIOD '' - ~ o -- --- -- - ~ : .-_. .__ - 4 ~ ~ ~ . ;.. C . ~. ~ , Z.-g' .~ ~... ., .• ' `, .~.. ~ r .. r FACILITY _ ,~ ~. .n': ~ - . . ~ . _ r ; .. n ~ YEAR MO .D i t cYEAR MO DAY ~p .. ~ ~. ? r m " O ~ '.'.FRaM LOCATION ,. ~~.78 .(5 raSl Ml.~~ ~r. E~}, ~r i ^ ^T0 ~. . ,~ •; ~ r ~ , ) . . - ~ N C < ~ P'!' Y : i L L L FJ .4` ,l :: c~, P :t Y.~':i-(~E y n;, .'. ° a. -• l1a1I1 = /11-131 IM-27l = ~ ~ ~- Y1a371 R8-1S) Hairy- -NOTE: Read instruetlons 6el0re eompfetinp this loan. ,.A ,~ ;' ,~ I3 Cmd On)y/ . GUANTiTY ORLOADING b.- b~ '! 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W -, i NAMERIjLE PRPICIPAE:EXECUTI~E 6PFIGER .~ ~cEJhIFY t7NDFT P6p/~BY~F LX>~I }NA~1 MATtE YER56NALEY EkAMINED -'u .-+~ -.:_ -' ' I : ~TELEPRONE ., .`.~` ~.:~ ~ OATE >- -~- I DA~~II FA311L01R W1Tll ifl FORMA710I/SUBMITTED NEREIIFAND BASED - V q"""' , IQ'~ 'f~" _ _ ._ H :.... r m:_,c THOS .• ._pjn.y: _ _ - '> v O G - ' _, .~ _,..__Q .~ n i)"_... ~ . ON MY~INWIRT OF E IYDIYIDUAl3 IYMEDIATELY RESPON510LE~OR _ - __ - pp gip.. V r~ " = '- - Tf'--~ ~~-~. 5: '_. BTADIINQJHQ INP9RMATIUN. I~EtlEVE TNP BUBMITTED INFORMATIpN/ - - ~: ~+'..~. Y ~ _ ~ W ~- C ~, '.:'nf:= -:... ~ -•. - ' . u . ~ $ TRDE, ACCURATE /IND'COMPLETE~.AA AW~rRETHAD THERE 7RE5((i Y _. ".'.~-' ••a.. '.• ~..t~.- :O -~'C t~S f u-:` ~~,'~~_LL ..r ~-. ~,~z~?1~,[y.~.., `JfIFlCANT ~TiLLTIE3.'FOR 9UBM(Gf7NG'FAISE:INtORMAT101Fj INCLUDING _ - - . `~ Ib 8 E1 IdI. ~ A. 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