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pERMRTEE NAME/ADDRESS (Indede Facillry NmndLooanon l/Di$erenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MRDES) FORT ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMR~
<br />(n- 91
<br />IS OMB No. 2040-0004
<br /> )
<br />a- * w , ^ ^ Approval expires 05-31-98
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<br />NAMERITLE PRINCIPAL FXECUTNE OFFICEfl I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />E INFORMATION SUBMITTED HEREIN
<br />AND BASED ON MY
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<br />INQUIRY OF THOSE INDNIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />I BELIEVE THE SUBMITTED INFORMATION IS TRUE,
<br />THE INFORMATION /,~ / ~~
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<br />' ' I PENALTIES FOR SUBMRTING FALSE INFORMATION INCLU
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<br /> 1001 AND 33 U.S.C.
<br />POSSIBILITY OF PINE AND IMPRISONMEHr. SEE 1e U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE '" J
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<br />TYPED OR PRINTED § 1319. (Perettiet antler I/rese srelutes mey Include pries up m 510,000 end w
<br />me..imum lmpreonmerx of beMeenamamhs end5yeen.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY woutt IONS (rtererence an atrecnmenrs nere)
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<br />EPA Form 3320.1 (08.95) Previous editions may not be used.• (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
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