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<br />NATONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM MPOES)
<br />DISCHARGE MONITORING REPORT (DMR~
<br />(1-16) nb 9)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />(2621) T12~23) (2425/ ' v 86-21) ' (28-29) ' (3631)
<br />Forth Approved,
<br />., , ~ ~ ,. OMB No. 2040-0004
<br />Approval expires 05-31-9R
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<br />PARAMETER (46-53) (5981 (3845 48-53f (54-81) EX OF TYPE
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<br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM lAW THAT I HAVE PERSONALLY EXAMINED AND
<br />ATION SUBMITTED HEREIN; AND BASED ON MY TELEPHONE DATE
<br />
<br />:ichard Mills INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONS18LE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
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<br /> POSSIBILITY OF FINE AND IMPR ISONMEM. SEE 18 U.S.C. § 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTVE
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<br />TYPED OR PRINTED § 1319. (PoneM/es antler wse sr4tulea may inclutle lures up ro E/0,OQ7 entl a
<br />maximum imprisonment or beMeen6monW enCS yearn.) OFFICER OR AUTMORRED AGENT R
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
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<br />EPA Form 3320.1 (OB-85) Previous editions may not be used. ,(REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) D ~ T ~ h / ,t ~ ~ rt i ~-1 r ~ ~t PAGE T OF
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