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<br />NATIONAL POLLUTMT DISLNMOE ELIMINATION SYSTEM lNPOESI Form Approved. ~
<br />DISCHARGE MONITORING REPORT IOMRI „ ~ ~ „ ~ ,,, ,,, ,~ON18 No. 2040-0004 -. .
<br />z-I61 17-191 "r , ti.•1 1, +~ -
<br />Approve expires OS-31-98 i
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERn Fr UNDER PENALTY of LAw rllwr I NAVE PERSONALLY ExAMINEO Mo TELEPHONE DATE
<br /> AM FA MILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED ON 7
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR / ~ /
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<br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS ~ n
<br />h~ichnrd ~.}1 ~IS TRUE, ACCUMTE MD COMPLETE. I AM AWME THAT THERE ME
<br />SIONIFILANT PENALTIES FOR SUBMITTING FALSE INFORMATON
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<br />TNEPOSSIBILITYOFRNEMDIMPRISONMENT. SEE I6U.S.C.11001MD3] ~~
<br />610NATURE OF PRINdPAL EXEdJTNE n .7 1~ 7 QQ
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<br />COMMENTS AND EXPLANATION Of ANY VIOLATIONS /Reference el/ srlecAmenGS here!
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<br />EPA Fwm 3320-1 108-95) Previous editions mey~bs used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.! n c -r ; ~ 7 „ ~ (, I, ~ ~ _ 1 } T ~ PAGE ; OF
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