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PERMfTTEE NAME/ADDRESS (Include Faciliry Nmne/[«mion iJDi$erenf)
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<br />NATONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM MPOESI
<br />DISCHARGE MONITORING REPORT (OMR~
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<br />PERMR NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />(70-III (Z1-1J) l2a~5) R&2]) (1&t91 (30Jr)
<br />Fonn Approved.
<br />. , T ^ ., OMB Na. 2040-0004
<br />Approval expires 0531-95
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I DERn Fr UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />MY TELEPHONE DATE
<br /> AM FAMILIAR WRH THE INFORM ATION SUBMITTED HEREIN; AND BASED ON ~ ~
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<br />~IchTLrd "')()15 INQUIRY OF THOSE INDMDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATON IS TRUE, / / 1
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<br />~ PENALTIES FOR SUBMITTIN G FALSE INFORMATION, INCWDING THE lU 1
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<br /> POSSIBILITY OF FINE AND IMPR ISONMEM. SEE 1B U.S.C. § 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE '
<br /> § 1318. (PenWas untler Nate sreMas may Inclutla lines up ro f10,000 eM ar OFFICER OR AUTHORIZED AGENT
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (F+ererence en a[recnmenrs oars)
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<br />EPA Form 3320-1 (OSA5) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ^ ,T T r ., / ~ ~ .~ ,1 1 ~_ 1 ~ ~ f, PAGE OF
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