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<br />FACILITY
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<br />MATIDNAI POLLUTANT OISCHAROE ELIMINATON SYSTEM (NPDE$I
<br />DISCHARGE MONITORING REPORT lOMRI
<br />11-161 I7-191
<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />YEAR MO DAY YEAR MO DAV
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<br />!16711 l17-731 111-15I IY6I7I 178-191 /3P31/
<br />Form Approved.
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<br />., `, Approval expires 05-3T-98
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTI FY UNDER PENALT' OF LAW THAT I NAVE PERSONALLY E%AMINED AND ~ TELEPHONE DATE
<br /> AM FA MILIAR WITH THE INFORMATON BUBMITTED HEREIN; AND BASED ON /
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR - /
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<br /> THE POSSIBILITY OF FNE AND IMPNSONMFNT. SEE to U.S.C. F 1001 AND ]] 610NATURE OF PRINCIPAL EXECIlTNE
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<br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS lRererence s// ettsc/Imsnts here!
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<br />EPA Form 3320.1 108-95) Prevloue edmone may ba used.
<br />(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) .,
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