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<br />NATONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM MPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR{ ^ OMB No. 2040-0004
<br />a-fs) m- 91 1 ' ~' Approval expires OS-31-98
<br />PERMIT NUMBER DISCHARGE NUMBER ~ _ ~• 4' ti~~'n'?-
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<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 46-53 5461) 38J5) 4G53 (5461 EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNRS
<br />lozm) ANALYSIS
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<br />6&70
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />qM FAMILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HER NALLY EXAMINED AND TELEPHONE
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<br />AND BASED ON MY - DATE
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<br />Richard AIIIS INOUIRY OF THOSE INDIVIDUAL
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<br />THE INFORMATON S IMMEDIATELY RESPON
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<br />SIBLE FOR OBTAINING
<br />FORMATION IS TRUE /
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<br />ACCURATE AND COMPLErE 1 AM AWARE THAT TH ,
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<br />R PENALTIES FOR SUBMITTIN ,
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<br />G FALSE INFORMATIO
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<br /> POSSIBILITY OF FlNE AND IMPR ISONMENT. SEE 1e U.S.C. 41001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED § 1318. (Peneltles untler Ihnse a
<br />mexrmum lmpdsonmerR Ol Defwwe mrures may Inc/utle fines up b 510,000 entl w
<br />n6mmr5s entl5 yeersJ OFFICER OR AUTHORIZED AGENT
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY vIOLAI ILrrv~ (nererence ell armcnmenrs oars)
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<br />EPJ1 Form 3320.1 (118.95) Previous editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) n ,} ro F T / n T „ fl I .,-) G n h PAGE ~ OF
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