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PERMITTEE NAME/ADDRESS (Include Faciliry Name/Lat'ation ifD~erenr/ NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDESJ
<br />NAME DISCHARGE MONITORING REPORT (OMR;
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<br />Form Approved.
<br />OM8 No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE
<br />INFORM LAW THAT I HAVE PERSONALLY EXAMINED ANO
<br />ATION SUBMITTED HEREIN
<br />AND BASED O '.
<br />~ TELEPHONE.
<br />' DATE
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<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING ;tis~~a.'"~ '
<br /> THE INFORMATION. I eELIEVE THE SUBMITTED INFORMATION IS TRUE: /
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<br />ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT
<br />PENALTIES FOP SUBMITTING FALSE INFORMATION, INCLUDING THE
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U S C 4 1001 AND 33 U.S.C. ~
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE L'I .IU Yr dM~ {~LU
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<br />•TYPED OR PRINTED g 1319. (Peneaies untler these srefules may include rings up ro 510,000 entl or
<br />maximum impdsonmen(o/6eMeen6monfhs entl5 yeers.J OFFICER OR AUTHORRED AGENT EA
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<br />SF,TTLEASLF. SOLIDS LIMIT APPLIF,'" ONLY IF <=1OYR,2gNR PRZCIP
<br />TS:i E IhO;i LINZTS :ILL NOT HE APPLIED TO RF.PORYED hEA$O:~tS
<br />EYENT IS CLAIMED. ZF CLAIM ApA6OYED 9Y H4CD,
<br />NT.S - SP,E I.A. 2, PC. 5 FOR AUACBM.oF PROQF
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<br />/A Form 3320-1 (OB-95) Previous edlhons may not be used ruJ , ;(REP,LACES,EPA~F.ORM T,,,,~0_WHICy-MAX NOT BE USED:)°" `°}~~ ~"j / /~' /'~ y` ~ ~ ~ ~ ~ i'- PAGE OF .
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