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PERMITLEE NAME/ADDRESS (Inc(1de Faclliry NmndLocaion i/Di$ermq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPOESJ FORTI ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMR~ OMB NO. 2040-0004
<br />Rasl !rr- sl °' ~ ~ r• Approval expires 0537-88
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAA Wmi THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOBE INDIVIDUAL S IMMEDIATELY RESPON ;
<br />SIBLE FOR OBTAINING
<br />ichard A1))IS
<br />P THE INFORMATION, I BELIEV E THE SUBMITTED IN FORMATION IS TRUE,
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<br />' ACCURATE AND COMPLETE. 1 AM AWARE THA7 TH ERE ARE SIGNIFICAM
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<br />I_nvironmrnt~l I•.1'.n~nar PENALTIES FOR SUBMITTIN G FALSE INFORMATION,
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<br />NG THE
<br /> ppSSIBILITYOFFINEANDIMPR ISONMENi.SEE18U.S.C.4101)tAND33U.S.C.
<br />SIGNATURE OF PRINCIPAL EXECUTVE
<br />TYPED OR PRINTED § 1315. (PenelUes untler Noce smnrtac mey Inclutle Ilrlac up to SrO,ooo erM or
<br />maximum lmprisonmprx of baMeenemomhs antl5yeBn.) OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLA I luny (Hererence a( anecnmenrs Here)
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<br />EPA Form 33261 (08.95) Previous editions may not be used. (REPLACES EPA FORM 7~0 WNICH MAY NOT BE USED.) n n t ~ n / n i ~ r() ~_ 1 ; ~ r. PAGE OF
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