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PERMTTTEE NAME/ADDRESS (Include Facility Nmne/Locarion IfDi$enmq
<br />NAME
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<br />LOCATION
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<br />NATIONAL POLLIfTANr DISCHARGE ELIMINATION SYSTEM MPDESJ
<br />DISCHARGE MONITORING REPORT (OMR~
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
<br />FROM Dq D1 ~: TO ?n ^r 17
<br />(40.411 (42-431 (4/431 (46-411 RB-48) (3601)
<br /> Form Approved. I
<br /> OMB No. 2040-0004
<br />4 T ~ " Approval expires OS-31-96
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<br />PARAMETER (46-53 (54-61) (3B<5 4E53 (541) EX OF TYPE
<br />(32J7) AVERAGE MAXIMUM -UNITS MINIMUM AVERAGE MAXIMUM UNfTS
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<br /> REQUIREMENT -. - ~ , ~'.
<br />NAME/TITLE PRINCIPAL E%ECUTRIE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF
<br />ILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY E%AMINED AND
<br />ATION SUBMITTED HEREIN; AND BASED ON MY
<br />~' TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE, ~~ /
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<br />Q.IChB rd Mllls
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN
<br />I AM AWARE THAT THERE ARE SIGNIFICAM
<br />G FALSE INFORMATION
<br />INCLUDING THE ~~ r
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<br />97O-S7O-2712
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<br />Environmental A^.anager
<br />POSSIBILfTY OF FINE AND IMPRI
<br />§ 1319
<br />(Porre/ifes under mesa s ,
<br />SONMEM. SEE IB U.S.C. § 1007 AND 33 U.S.C.
<br />toMes may inclutle lures u
<br />ro 510
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<br />SIGNATURE OF PRINCIPAL EXEClIT1VE /
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<br />TYPED OR PRINTED .
<br />mex/mum impdsonmenf or oeMea p
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<br />nBmamhs entl5 years.) OFFICER OR ALfiHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY vIOLJ1IIONS (nererence eu anacnments here)
<br />ALT~kNAT? LI"'T°~ °^' '"~; - .i'TTr.FA?LF S'7LLD; • •
<br />(L'Tf' 7 ) Ann,,Y n.1{.v TF !- ?1'•n• 'll'1'P {11'OC(^ ^,r^nT .~
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<br />EPA Form 3320.1 (09A5) Previous editions may not be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) PAGE OF
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