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ADDRESS ~ ~~ ~ ~ ~~. ~ ~ ~ ~~
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<br />FACILITY B OGd I ~ NO. ~ h`! I ML
<br />LOCAT1oN1' ~§ O!~! $ hqr C C1 #3 $ ~'• ~ ,`+
<br />OaTTIL: FnltLLlo-~C!`'3 ~. ~~~II•d J~. : &~9IN~ S"!~`R
<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM //NPDESI OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT /OMR) !`$ ~ l~30F~v
<br />PERMIT NUMBER DISCHARGE NUMBER ~ '"• k ~ ~~I••• 1?I+LTs~
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<br />FROM TO
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<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO,
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<br />NAME/'TITLE PRINCIPAL EXECUTIVE OFFICER 1 tertllr Y er pene Ir O law Ihet. IhN dONmenl and NI oltochlnenb were
<br />prcpored Yllder m~ direcuon or mpervhlon m oeeordontt wuh ^ system eesllned
<br />TELEPHON
<br />E
<br />DATE
<br /> to tenure Chet quoNRed personnN P~H7 6ether and evoluule the Infonrulbn ~// /~
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<br /> snhmltted. hosed on my Inquiry of the person or penom who monate the system, ~%~ /~/
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<br />or lhaoe penorls directly respotdbk for pther111` the Informolion, the Informollon ~
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<br />submitted h., b the best of my knowkdSe end beNef, true, uttvnte, end mmpkte.
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE ~~~ ~~ ~
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<br />PED OR PRINTED InelYamL the porsibllity of ene and Imprisonment for krawln~ vlolsUoln OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS IR~f~r~nc~ s// ~tbchmlrnts h~r~l
<br />OIL ac OR~~81= - I. Ii. ~. L, ~'t~. 4. t3FtTFV!_Y S~3~lf'LIi~3C IG~95TTd41Cl"IOl~J~ -- ~. C. 30, ~°'G. $U.
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. Ql~it~.Q(; f ~}'F~Y1~,~4-~~~Tffl, PAGE $OF
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