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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME „_..:30 Jf"'.' . r.C. C0VF P.
<br />ADDRESS InlHT IR L.IW I. ND !" R 0,;!-Ei i
<br />C10 51; 4
<br />FACILITY till; fj;',_,?.i'i i; i•' E't?r "=,.• r
<br />LOCATION , . -,
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM :i 1. ( * t TO s. c.: ?..) .k -; .'.
<br />i ' NOR
<br />F -M FINAL
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before dompleting this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO
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<br />FREQUENCY
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penally of law that this document and all attachments were
<br />-- TELEPHON E DATE
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<br />` prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information ?
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<br />- submitted. Based on my inquiry of the person or persons who manage the system,
<br /> or those persons directly responsible for gathering the information, the information
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />
<br />IGNATURE OF PRINCIPAL EXECUTIVE
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<br />YPED OR PRINTED'` I am aware that [here are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing violations OFFICER OR AUTHORIZED AGENT CO
<br />E NUMBER YEAR MO DAY
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<br />COMMENTS ANU hAFLANAI IUN Ur ANY VIULAI IUNJ (Kerelrence all a trrrgaclum}?tenrs nerej
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<br />EPA Form 33201 (Rev. 3/99) Previous editions may be used. t7v'r)?. (.jE IS-j&,q 4-p4tj-prm. PAGE t gOF '
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