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<br />DISCHARGE MONITORING REPORT (OMR;
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />Form Approved.
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<br />Approval expires OS31-g5
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<br />NAME/TITLE PRINCIPAL E%ECUiRIE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR W(h1 THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDNIDUAL S IMMEDIATELY RESPONSIBLE FOR OBTAINING / 7
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<br />'ilII9 THE INFORMATION, I BELIEV E THE SUBMITTED INFORMATION IS TRUE, ~~
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<br />PENALTIES FOR SUBMITTIN I AM AWARE THAT THERE AFiE SIGNIFICANT
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reverence all etfachmenLS here)
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<br />EPA Form 3320.1 (OBA5) Previous editions may not berused. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) PAGE _ OF
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