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<br />NATIONAL POLLUTANT OISCNMGE ELIMINATION SYSTEM INPDES) Form Approved.
<br />DISCHARGE MONITORINO REPORT lDMRI
<br />11-761 17-191
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<br />ii: 7L:; :~ OMB No. 2040-0004
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<br />( ; 11 -: . ,:) Approv9l expi~ea 05-31-98 '
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<br />c152
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<br />!14771 I71-73/ /2<-75/ /I6T7I I7B-79/ !34371 NOTE: Raed InahuCOoro befCFe completlnp thb form.
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<br />NAME/TITLE PRINCIPAL E%ECDFIVE OFFICER I CERTIFY UNDm PENALTY of uw TNAT I NAVE PERSONAUr ExuAiNm AND
<br />AM FAMIVAR WITH THE INFORMATION SUBMITTED NERDN; AND eASEp QN
<br />) ~ TELEPHONE DATE
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<br />R / C ~ r7/( ~, ~ • / Q~' ~ ~ MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONABLE FOR
<br />OBTNNING THE INFORMATION
<br />I BELIEVE THE SUBMITTED INFOIMATION IS .
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<br />ACCl1MTE AND COMPLETE
<br />1 AM AWA11E TNAT THEPE ME ~
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<br />AGNIRCANT PENALTES FOR SUBMITfINO FALSE INFORMATON
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<br />i~ (/ /. r U,E THE Po5S1&VTr OF flNE AND IMPRISONMENT. SEE 18 U.S.C. L 1001 AND 9a SIGNATURE OF PRINCIPAL EXECUrn/E U "~- i~ n ~1
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<br />TYPED OR PRINTED .r>n,erbxAn hprsmNnEwa.e..«nemonsu.nds Y,MAI OFFICER OR AUTHORf2E0 AOEfET CODE NUMBER YEAR MO DAV
<br />GOMM[N IS ANU [AYLANAIIVN Oh ANT VIVLAIIVNS /Here/enCe s!/e(EeC/1TBIIls Oe/B/
<br />EPA Farm 3320.1 108-55) Pre4ioue editions mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.1 ; L y / 71 1 1 .~ - 1 1 1. •, PAGE I OF
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