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PERMITTEE NAME/ADDRESS (/ndude FacJrrr Name/[oration fD~errnQ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />NAME F' Z C h F T fi I H E ~ h C C E ::~ I r V, L L l DISCHAS GE MONITORING REPORT (DMH;9
<br />ADDRESSNEW ~LH !!INE OCC( CC G '~
<br />'" T u~= c T =' r te! C F y E PERMIT NUMBER DISCHARGE NUMBER
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<br />Form Approved.
<br />C I N C n OMB No. 2040-0004
<br />Approval expires 05-31-98
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OFI
<br />AM FAMILIAR WITH THE INFORM .AW SHAT I HAVE P~RSONALLV EXAMINED AND
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<br />~ x INQUIRY OF THOSE INDNIDUAL
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<br />E THE SUBMITTED INFORMATION IS TRUE
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<br />I AM AWARE THAT THERE ARE SIGNIFICANT {
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<br />POSSIBILITY OF FINE AND IMPBI ,
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<br />SONMENr. SEE tB U.S.C. 4 t00t AND 33 U.S.C.
<br />S NATURE OF PRINCIPAL EXECUlIVEi C
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference e/I attachments here)
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<br />!PA Form 3320-1 (OB-95) Previous editions may not be useU, ~ (E)EQWCES EPA FORM T-40 WHICH MAY NOT BE tlSED. PAGE OF
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