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PERMITTEE NAME/ADDRESS (!nc(ude Facility Name/Locanon i/DiJ~erenq
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<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SVSTEM (NPDES) FORfI ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004
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<br />YEAR MO DAY YEAR MO DAY
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<br />NOTE:" Read Instructions belore completing this form.
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<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER lCertiy untler penalty of law lnat Nis oocumanl antl all attachments were
<br />tl TELEPHONE DATE
<br /> preparetl untler my tliredion or supervision In accortlanca wM a ryslem oesigne
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<br />~ ~ ~ ~r i i r. t ' •., ~ ~ tp assure that quahfleo personnel property gxihar antl evaluate Iha Information _
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<br />- submmetl. Basso on my inquiry of the person or persons who manage the ryslem,
<br />the Inbrmalion
<br />or Nosa persons tlireNy responsible for gaNering the Information ~~~
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<br />submittetl Is, to me best of my knowletlge antl belief, true, exurete, antl complete. SIGNATURE OF PRINCIPAL EXECUTIVE r~ '•~~ ~ ~J 4 3~~. G U~' ~~G.
<br />
<br />TYPED Oi'i PRINTED I am aware Ihat Nere are signillrant penalties for submming false information,
<br />Incluol the pssipili of fns ono im risonment Ipr knowin violations. OFFICER OR AUTHORIZED AGENT A
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<br />NUMBER
<br />.YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
<br />EPA Form 3320-1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
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