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PERMTTTEE NAME/ADDRESS (Include Facility Nemr/Loralion ijDifferenr)
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<br />FACILRY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE EUMINATON SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR;
<br />(2181 (m e)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />(202/1 (22-23) (24-25) R&2]) RB-291 (3P3/)
<br />Form Approved.
<br />„ , , -~ _. OMB No. 2040-0004
<br />I •• ^ p ` Approval expires OS31-98
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<br />A 4NOTE: Read Instructions befol~leting this loan. ~.
<br /> (3 Cerd Ony) QUANTITY OR LOADING (a Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (aB-53) (5a-B1) (38-45) (4653) (54-61
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<br />NAME/1TTLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF l
<br />AM FAMILIAR WDH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMfTTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MV TELEPHONE DATE
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<br />1 r'i!I i INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION
<br />I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE i
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<br />ACCURATE AND COMPLETE
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<br />I AM AWARE THAT THEflE ARE SIGNIFICANT /
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<br />PENALTIES FOR SUBMITTIN
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell eDechmentS Here)
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<br />EPA Form 33261 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ n 1 n T / ~ T ~ 11 ~ ~ _ T 5 ~ rl PAGE OF
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