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PERmirtrit NAME/ADDRESS Unchide <br />null Name /1,(4ention 41 difierent) <br />LIAME <br />A DPAELIf _ - <br />- <br />LOCATION <br />PARAMETER <br />( 9-3/) <br />Dis <br />TYPED OR PRINTED <br />SAMPLE <br />MEASUREMEN <br />ontolm rr <br />Rt4au I ft ES /RUT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REquirtemat4T <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REctulAltmeur <br />SAMPLE <br />MEASUREMENT <br />rEnmyr ' <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />Orichmir <br />qtbuinitmiste <br />SAMPLE <br />MEASUREMENT <br />Pitotmlt ' <br />REQurnirMANT <br />SAMPLE <br />MEASUREMENT <br />pIAMr <br />REQUi*Emert <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />(3 CI:1 QUANTITY OR LOADING <br />(54 <br />AVERAGE <br />COMM EN I %ND X PL A NATION OF ANY VIOLATIONS (Rejererree aiX aitachmenit here) <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM INP0/...” <br />DISCHARGE MONITORING REPORT tirmR) <br />(2 19) (17 19) <br />PERMIT NUMBER <br />FROM <br />MAXIM UM <br />YEAR <br />MO DAY YEA <br />110 /// (/) 11? <br />UNITS <br />MONITORING PERIOD <br />TO <br />(4 Card Mir ) <br />I CERT FY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY ExAm■NED <br />AND AM FAMILIAR WITH THE NFORMATION SUBMITTED MEREIN, AND BASED <br />ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br />45 TRUE, ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG. <br />ranf, ANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br />THE POSSMAJTY OF FINE AND IMPRISONMENT SEE le USC I 1001 AND <br />111,15 C 5 1319 fArnahsep under these statutes mar Include frnee ap 40 Sto <br />and or mammon, Impricantarnt a/ $,tworn $ months and :5 years <br />MINIMUM <br />r DISCHARGE NUMBER <br />MO <br />DAY <br />71115 / 2455451-116431) NOTE: Read Inatr clions before completing this for <br />DUALITY OR CONCENTRATION <br />(46.53) 45$451) <br />AVERAGE <br />0. 0 oa <br />M A *11.1 UM <br />0 6 0 0 0 o <br />0 , 00 / <br />ssr" <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />CODE <br />UNITS <br />TELEPHON <br />Form Approved <br />OMB No, 2000-0016 <br />F NC <br />45 2-453) (64-68F <br />NO. <br />EX <br />NUMBER YEAR <br />30 <br />0 A T <br />M O <br />S AMPLE <br />I YPE <br />1554 7444 <br />DAY <br />