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PERMITTEE NAME/ADDRESS pweYJrFacllryN.w/Loea,ar f/D(Qirwrq
<br />NAME I~I~!~I~ ffdESaURC~S L%MI'T~~3
<br />ADDRESS ~ ~~ ~ ~ ~©' ~ ~ ~ ~~
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<br />Form Approved.
<br />NATIONAL POLLUTANT DISCNAROE ELIMINATION SYSTEM //NPDESI OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT fDMRI ("I ~RlCI~C
<br />PERMIT NUMBER ascNAnaE NuMeER F- - ~ 11~4t~L C}~I-i' ~
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<br />NOTE: Reid imtructlora Miof~ complytiny this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO,
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFlCER ' "^"y" er pem ty o "w thu thladacument "nd au ettuchmentt were
<br />prtpued under my direction or superrlslon In "eeordance wllh ~ system desi`ned TELEPHON E DATE
<br /> to atsurt Ih"t qu~NBed personnel properly `ether and e~dude the InformHbn
<br />snbmined. Bated on my Inquiry of the person or persoro who nun~ee the system, ///JJJ /
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<br /> or those penoro dlrtetly resporolbk for ptherlnE the Inforrrutlon, the Information ~ /
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<br />~ ~ G ~ I f' C submitted b. to the bnt of my knowkdBe and DeMef, true, aceuntq end mmpkte.
<br />610NATURE OF PRINCIPAL EXECUTIVE /
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<br />. i am await that there art slEnleant penaltla for submtttln~ fsbc Information,
<br />T1fPED OR PRINTED lndudln` the possiblllly of Bne and Imprisonment for knowln` elolatlona OFFICER OR AUTHORIZED AGENT CODE NUMEiER YEAR MO DAY
<br />COMMENTS AND EXPLANATION or nnT vw~A l Iuns IHaer~nc~ sn ~mcnm~nfs n~r~~
<br />I~TL .°~ GR~r~,SS - I. I~.:I. ~, P0. ~. QRTRLY S~rf~RLl~lfl I6VSTE3UflT~i~lik9S - I. C. ~{.}, P0. %Q.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. (~~}~ ~. ~'~/£}~~~}fS'~~'4' ~J#I'Q~TIIt. PAGE SOF '
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