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PERMITTEE NAME/ADDRESS (Include FncNlry NmndLocation i/Di$erenq
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<br />NAME/TITLE PRINCIPAL IXECUTNE OFFICER I CERTIFY UNDER PENALTY OF lAW THAT I HAVE PERS
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<br />TTED HER ONALLY EXAMINED AND TELEPHONE
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<br />AND BASED ON MY DATE
<br /> AM FAMILIAR WRH THE INFORM ATION SUB
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<br />I INQUIRY OF THOSE INDIVIDUAL
<br />I BELIEV
<br />THE INFORMATION S IMMEDIATELY RESPON
<br />E THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE, / /, ~
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<br />ACCURATE AND COMPLETE. I AM AWARE THAT TH ERE ARE SIGNIFICANT ~ ~ /J 970-870_•Z7~~
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<br />EnvlronnlentEfl 'Uanager PENALTIES FOR SUBMITTIN G FALSE INFORMATION, INCLUDING THE _ (' ~
<br /> POSSIBILRV OF FINE AND IMPR ISONMEM. SEE 18 U.S.C. 4 1 W1 ANO 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED 1318. (Feraltles untler Mace
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Helerence en attachments here)
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<br />EPA Form 3320.7 (08.95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) n ,1 ~ ^ „ / n T . ,I , .,_ , ~ , ,t PAGE OF
<br />NATIONAL POLLIfTANT DISCHARGE ELIMINATON SYSTEM (NPDES) FOrm ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMR~
<br />" OMB NO. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER ~ _ +..•
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<br />YEAR MO DAY YEAR MO DAY I
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<br />(zaz+) tzz~zs) tzazs) Razz) rze-ze) (30.3+1 NOTE: Read IrLSVUCtions beto co leting this forth.
<br />Y OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />541 (3845 (4653 (54-61) EX OF TYPE T
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