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<br />NATIONAL POLLUTMT DISCHMOE ELIMINATION er9TEM /IAtPDE$1
<br />DISCHARGE MONITORING REPORT /DMRI
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<br />Y MO DAY YEAR MO DAY
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<br />Form Approved.
<br />,. _ __ . , . - ~ ~ • ,.:, I { QM~ No{ 2040-0004
<br />1 ,~ ~.1 Approval exgilPp OS-31-98
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<br />PARAMETER 13 Card only! QUANTITY OR LOADING ~ Only QUANTITY OR CONCENTRATION
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cERn
<br />AM FA Fr unDER PET+ALTY of
<br />MILIM WITH THE INFOR uw rNAT I NAVE PERSONALLr ExAMINED MD
<br />MATION SUBMITTED HEREIN
<br />MD BASED ON ~ / ~' ~ TELEPHONE DATE
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<br />Mr INOUI11r OF THOSE INDIVIDUALS IMMEDIATELr RESPONSIBLE FOR
<br />OBTNNINO THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION 19 I
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<br />TRUE, ACCUMTE MD COMRETE. I AM AWME THAT THERE ME
<br />SIGNIRCANT PENKTIES FOR sUBMITTING FALSE INFORMATION, INCLUDING
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<br />'-((' V LJ ' I ` , .1 THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 18 U.S.C. 1 1001 MD 33
<br />BIONATURE OF PI
<br />INCIPAL EXECUTNE I L' I V L
<br />V U.S.C. E 7310. lAxWd++r+ry+r nuw Nnrh+ m+Y lnelW+ ~+,++,P ro ! 10.00[1 ,
<br />TYPED OR PRINTED •ManNVin,+n inpla•rwntW MrrwnemarN+rM6yva/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lReferenea s// srcechmenfs hare)
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<br />EPA Form 3320-T 108.96) Previous aditiona may be used. IREPLACE6 EPA FORM T-40 WHICH MAY NOT BE USED.1 000 64 / 9 9 0 91 4- 0 9 2 3 PAGE 1 OF
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