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PERMITTEE NAME/ADDRESS (Include Fan(ip~ Name2ocarinn i/Di/jerenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMR; OMB No. 2040-0004
<br /> Approval expires OS-31-9R
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<br />PARAMETER (46-53) ~ (33-45) (46-53) (54-61) EX OF TYPE
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<br />NAME(fITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
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<br />J INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE, / ~ ,, ~ ~ / ~
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<br />R(C ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN I AM AWARE THAT THERE ARE SIGNIFICANT
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<br />POSSIBILITY OF FINE AND IMPRISONMEN75EE IB U.SC 41001 AND33USC. _ _ _
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<br />TYPED OR PRINTED § 1319. (Ponettias antler these statutes may inclutle lines up ro 510.000 entl or
<br />mex,mum,mpnsonment of between6monlhs entl5years)
<br />OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR -
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<br />DAY
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<br />EPA Form 3320-1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM TAO WHICH MAY NOT BE USED.)
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