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PERMRTEE NAME/ADDRESS (Inchule Faciriry Nmne/Loea(lon ijDl$erenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR~
<br />(Y-161 (O- 91 ... T ^ -.
<br />^11771 tiD nn'1 a v"1
<br />PERMIT NUMBER DISCHARGE NUMBER ^+ .: ~,
<br />Farm Approved.
<br />OMB No. 2040-0004
<br />Approval expires 05-31-98
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<br />FACILITY MONITORING PERIOD
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNOEfl PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE DATE
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON MY
<br />INQUIRY OF THOSE INDNIDUALS IMMEDIATELY PESPONSIeLE FOR OBTAINING ///
<br />::)Che rd NI(IIS THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATON IS TRUE, / ~7 / / ~ /
<br />ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFlCANT ~/ ~/ '
<br />Env(rOrl[rIP_tltH) ,~:UTIaOP_I' PENALTIES FOR SUBMffnNG FALSE INFORMATION, INCLUDING THE ~~. ~ ~ r~ . " ~ 70-870-2712
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<br />5 24 99
<br />POSSIBILIT'I OF FINE AND IMPRISONMENT. SEE 16 U.S.C. § 1001 AND 33 U.S.C.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED § 1319. (Poretim uMer Mase emtufas moy Incrutle /lose up ro f70,0o0 end a
<br />nxWmum lmprlsanmeix Or beMeen6monlhs entl5ybers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
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<br />COMMENTS AND EXPLANATION of ANY VIOLATIONS (nererence an armcnmens nere)
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<br />EPA Form 3320.1 (08-95) Previous editions may not be used.t ~ ' ~(REPLAdE$~EPA FORM 735 WHICH MAY NOT BE USED.) n „) c 1 / n n r) ry T n_ + C ~ ,( PAGE OF
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