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<br />NATIONAL POLLUTANT OISCHMOE El1MINATION SYBTFM //VPOESI
<br />DISCHARGE MONITORING REPORT (DMRI
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<br />PERMIT NUMSER DISCHMOE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
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<br />Form Approved. „
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF UW THAT 1 HAVE PERSONALLY E%AMINED MD
<br />AM FAMIUM WITH THE INFORMATION sUBMITTED HEREIN; AND BASED ON TELEPHONE DATE
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<br />~J G~1'V(.`. r/L-~rIJBY(.. MY INOMRY OF THOSE INDIVIOUALe IMMEDIATELY RESPONSteLE FOR
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<br />1 PA Form 3320- 108.95 Previous s ~ it7ona mey a used. (REPLACER EPA FORM T-40 WHICH MAY NOT BE USED.1 PAGE OF
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