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PERMfrTEE NAME/ADDRESS (include FaclLry NamdLOCOa~on i/Di$erenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONRORING REPORT (DMR;
<br />13-161 p]~ B)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
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<br />(36211 (22-33) (71-151 (78'Z]) (Z&~9) (30.31)
<br />Form Approved.
<br />~ ~ ..., OMB No. 2040-01X14
<br />Approval expires 0631-98
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<br /> (3 Cerd Ony) QUANTITY OR LOADING (4 Card Ony) GUANTITY OR CONCENTRATION NO. FREOUEN SAMPLE
<br />PARAMETER (46.53 5467 9<5) 46-53 54-61 EX OF TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WRH THE INFORM lAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BARED ON MY TELEPHONE DATE
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<br />kachard tiIIIIS INQUIRY OF THOSE INDNIOUAL
<br />THE INFORMATION
<br />I BELIEV S IMMEDIATELY RESPON
<br />E THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE -
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<br /> POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1B U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED § 1316. (Penalties untler tfrese statutes mry Include 9nes up ro f10,000 erH w
<br />madmum lmpnsonmentWbeMSen6mont/u end5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence ell attachments here)
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<br />EPA Form 3320.1 (118-95) Previous editions may not be used. (REPLACES EPA FORM 7-00 WHICH MAY NOT BE USED.) ~ ~ T 1 ,T ~ ~ ~ O rl 1 ~_ 1 ~ ~ n PAGE [ OF
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