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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESf Form ApprOVed.
<br />DISCHARGE MONITORING REPORT (OMR; OMB No. 2040-0004
<br />rz-1st nT- sl h ~ ~ ~ ^ Approval expires 0531-98
<br />'7D927154 n1Q A (^-1+9n +IC)
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<br />PARAMETER (48-53) 56-61 (38-05) (46-53) (54-87) EX OF TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAFi WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATON SUBMITTED HER NALLY EXAMINED AND
<br />EIN; AND BASED ON MY TELEPHONE DATE
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<br />Kichard ',ills INQUIRY OF THOSE INDNIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
<br />1 AM AWARE THAT THERE ARE SIGNIFlCANT
<br />ACCURATE AND COMPLETE
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<br />PENALTIES FOR SUBMITRNG FALSE INFORMATION, INCLUDING THE ~
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<br /> POSSIBILRY OF FINE AND IMPRISONMENT. SEE 1a U.S.C.4 1001 AND 33 U.S.C.
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<br />TYPED OR PRINTED merimum lmpnsonmenl of behwen8mpnths sntl5 years.) NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachments here) 'R
<br />uSvl,'Iri'+=. 19-9AY AYF.?A;?. _DN^?N*RATfDN `ISIV~ A vORRaL ART*°"'PTTr "4AN n^ ALT. 4•4r•.*• ~~~-e.T~~ OfSTlIT~.^n ,r,n
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<br />+OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) n~0,1 a 9 ~ 9q O d ~ ~-, ~ I PAGE
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