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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR)
<br />^rPERM1T NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM O 1 O 1 U 1 To U 1 0 3 S
<br />Form Approved.
<br />OMB No. 20440004
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICenily under penalty ollaw that this doament end all anachments were TELEPHONE DATE
<br />_ . , prepared under my direction or supervision in accortlance with a system designed
<br />to assure that qualAed personnel property gather and evaluate the intorma4on
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<br />W Gordon 'Peters subminetl. Bazed on my inquiry of Ne pereon or persons who manage Ne system,
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<br />Na Infonnatlon
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<br />e SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />'{ ~ TYPED OR PRINTED l am awa.efhat Nera ere slgniGCam penalties for submining false inbmslion,
<br />inclutlin the ossibili of fine and lm risonmant for knowin vidations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS ANO~EXPLANATION OF ANY VIOLATIONS (Ae/erence all attachments here)
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<br />L'.r.THAL TO SOm ^F TL'3T~HGANIS!IS, AND ATTACH ACUTE TOXICITY TES; dEPORT F;P,C TO i,tlH. COPIES OF ALL _._-~--- -
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