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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESI FOJm A
<br />DISCHARGE MONITORING REPORT (OMRI - ,OMB No: ZO
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<br />YEAR MO DAY YEAR MO DAY _.._
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<br />PARAMETER !3 Grd On/yl QUANTITY OR LOADING l4 Grd OnIYI QUANTITY OR CONCENTRATION Np. NEFDUENCV SAMPLE
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<br />(9Z-371 EX 'WALY~s TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS lem691 l6L6B1 !64701
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<br />,.,~, ftTLE PRINCIPAL EXECUTIVE OFFICER I ~ERnFY UNDER PENALrr of
<br />AM FAMILIAR WITH THE INFO uw TNAT I NAVE PERSONALLY E%M11NED AND
<br />RMATION SUBMITTED NERDN: AND BASED ON TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON918LE FOR
<br />/~ ~ : , , .-. OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />- ~ TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT TNDiE ARE - '
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<br /> SIGNIFICANT PENALTIES fOR SUBMITTING FALSE INFORMATION
<br />INCLUDING ''' ' ' ' ~ ' ' - ' ~ ~
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<br />THE POSSIBNTY OF NNE ANO IMPRISONMENT. SEE 18 U.S.C. f 1001 AND 33 t gIONATURE OF PRINCIPAL EXECUTIVE ~ ~ ~ ~ ,
<br /> U.9.G. f 131 e, lMYrln ,n M/ Nrr WtuM1, rery i1cA,0Y RM, W ro i JO,OelO AREA
<br />TYPED OR PRINTED narmuh,vnhWaemrAnrWbrwwremonrM rd6Wral OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
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<br />EPA Form 3320-1 108.95) Previous editions mey be used. IREPlACE8 EPA FORM T-40 WHICH MAY NOT BE'USED.1 ~ ~ PAGE OF
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