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<br />ADDRESS`!I21~'~ L,L:3 SOOTR, °~K11lN P4
<br />9100 PRiP "LNF'RAT. ~LR"LF.
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<br />NATONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) FORn ApprOVed.
<br />DISCHARGE MONITORING REPORT (OMR; OMB No. 2040-0004
<br />(z~re) (+~- e) '+ 1 ~': ' Approval expires OS31-98
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<br />PARAMETER (46-63) (54-61) (3845) (46-63) (5461) EX OF TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICERTIFV UNDER PENALTY OF IAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN: AND BASED ON MV DATE
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<br />INQUIRY OF THOSE INDNIDUAlS IMMEDIATELY RESPONSIBLE FOR OBTAINING LL
<br />F.1ClTc9YC1 )t 11115 THE INFORMATION, I BELIEVE THE BDBMnTED INFORMATION IS TRUE, ~ ~~ ~ /~] 97D 137D-2732
<br />ACCURATE AND COMPLETE. 1 AM AWME THAT THERE ARE SIGNIFICAM ///
<br />PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING THE
<br />~nVll'O!1f iP.ll tal Manager POSSIBILITY OF FINE AND IMPRISONMENT. SEE IO U.S.C.~1fg1 AND33 U.S.C. SIGNATURE OF PRINCIPAL E%ECl7TIVE ~/
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<br />TYPED OR PRINTED 5 1318. (Ponett/es antler these smhttes mey include fines up m 570,000 end or
<br />maximum impdsonmem of benveen6mon0a entl5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND ExrtANA71oN or ANY wutn l wNS (Nererence arI aaacnmenrs nere)
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<br />EPA Form 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) 0 0 2 5 ? / 0 0 ~ 4 1 ~-1 ~.: ~ 4 PAGE ,) . OF 7
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