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<br />NATIONAL POLLUTMT DISCNMOE ELIMINATION SYSTEM INPDESI Form ADProved.
<br />DISCHARGE MONfTORING REPORT IOMRI . ;OMB No; 2040-OQ04
<br />1-161 l7-191 ~• '`~ ~ 1 ~ ~ "
<br />. ,~ ; ~, ~ I , / J v / _ I .I I Approval expiree_ OS-31-98
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<br />-- ~ !16111 I22-131 114-151 176271 128-I9I !36311 NOTE: Reed Instruction bdors completing this form.
<br />PARAMETER !3 Ard On/YI QUANTITY OR LOADING !I Grd On/YI QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS rs2-ssl I6e-6g1 !63701
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<br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED MD TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFO RMATION SUBMITTED HEREIN; AND BASED ON .
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<br />I~1Ct1.9Tl~ {\s .:11]1 ,01 MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR /
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<br /> OBTAINING THE INFOIUTATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />ACCUMTE MD COMPLETE
<br />I AM AWME THAT THERE ME _
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<br />SIGNIFCANT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />THE POSSIBILITY OF FINE MD IMPRISONMENT. 9EE 18 U.B.C. E 1001 MD 9J BIONATURE OF PRINCIPAL EXECUTIVE
<br /> U.B.C. f tJ10. !lNII,B/,1 IIW MY AvumM nI,Y N[lld, rw, Ip ro t IO,OW AREA
<br />TYPED OR PRINTm wnmui,mn HrpnYVm~It of MtwwnemoneYaAM6YAVa1 OFFICER OR AUTHORIZED AGENT cooE NUMBER YEAR MO DAY
<br />COMMENTS AND tAYLANA I Ion or Anr VIOLA I wns lRererencs sn enscnmenrs oars!
<br />EPA Form 3320.1 108-951 Previous editions may ba used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) ~~ ` / , I .1 _ I PAGE OF
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