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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR~ OMB No. 2040-0004
<br />(3-161 ttl-61 ' ~ ~ ~ ApprOVBl e%p1r0605-,11-98
<br />PERMIT NUMBER DISCHARGE NUMBER ~ _ A~1)T~
<br />MONITORING PERIOD "T"-~ i• ~~°•~ ~^n T••T•~-1 ^~s'R,.
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />ml THE INFORM lAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
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<br />AND BASED ON MY TELEPHONE DATE
<br /> AM FAMILIAR W
<br />INQUIRY OF THOSE INDNIDUAL S IMMEDIATELY RESPON ;
<br />SIBLE FOR OBTAINING
<br />RAC hiI SCI Ir)~~~9 THE INFORMATION, I BELIEV E THE BDBMnTED IN FORMATON IS TRUE,
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<br /> ACCURATE AND COMPLETE. I AM AWARE iHA7 7H ERE ARE SIGNIFlCANT 2717
<br />970
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<br />Fnvlronr^rntal ".!~nrryer PENALTIES FOR SUBMITTIN G FALSE INFORMATION, INCLUDING THE - .
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<br /> POSSIBILRV OF FlNE AND IMPR ISONMENT. BEE 1B U.S.C. 41m1 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E%ECUTNE
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<br />TYPED OR PRINTED 4 1319. lr'enWa+ under these smMes may /rlc/ude titres up ro S/0.eD0 end ar
<br />merlmum lmprlsonmerR Ol beMeen6monfht end5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
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<br />COMMENTS AND EXPLANATION OF ANY VIOLAI IONS (Heterence ar a®cnmenrs oars)
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<br />EPA Folio 33261(OBAS) Previous etlitions may not be used? ^ ~ • ~ (REPLACES EPA FORM 7'~0 WHICH MAY NOT BE USED.) ~ ~ T I ~ / Fl T ~ rt } ~`~ S , 11 PAGE T OF
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