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PERMfTTEE NAMEIADORE85 (/M,L F.rWgNaWLoemla (1Dle6.nr0
<br />NAME .i :. '. .,. ~ _. .. ,. -
<br />FACILRY
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<br />NATIONAL POLLUTMT DISCNMOE El1MINATION SYSTEM NPDESI
<br />DISCHARGE MONITORING REPORT ID Rl
<br />1-f61 (7-191
<br />COOJU:.:ii 00
<br />PERMIT NUMBER DISCHMGE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
<br />FROM y '7 U TO
<br />/?aLl nJ.om re naJn rlA-191 1311.311
<br />Form Approved. t"
<br />L ~ ;: ~ q _ ~r • ~ , ,I ;OMB No., 2040-0004
<br />„ . ,I ,! ,F) Approvei expifpe 06-31-98~
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<br />~ QAT ~ 1 V:: ~ n i ;, Y . "!'.:
<br />NAME/i1TLE PRINCIPAL EXECUTNE OFFICER I CERTI
<br />AM FA FY UNDER PENILLT' OF LAW THAT I HAVE PERSO
<br />MILIM N/ITH THE
<br />NFO NALLY EXAMINED MD ~
<br />~! ~ TELEPHONE DATE
<br />_
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<br />RMATION SUBMITTED HEIIEIN; MD BASED ON
<br />MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION 19 ~
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<br />~' TRUE, ACCUMTE MD COMRETE. I AM AWME THAT THERE ME
<br />SIGNIFICMT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING , _
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<br />THE POSSIBILITY OF RNE MD IMPRISONMENT. SEE 18 U.S.C. F 1001 MD 77
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<br /> u.3.C. E 171Y. !/MWtlr uMr NrFr mturoa ro.Y ~. 5+r 4F ro i10,f1W S
<br />GNATURE OF PRINCIPAL EXECUfNE
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<br />TYPED PRINTED
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<br />OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />EPA Fwm 3320-1 (08.96) Pravlous adlDOne mey be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.1 0 Q ~ 0 ~ ~ v s n ~l n- o y z ~ PAGE i of
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