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PERMRTEE NAME/ADDRESS (lrlclude Faciliry Name/lncmlon jDi$erenp
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESf
<br />DISCNARGE MONITORING REPORT (OMR;
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />(20.211 (22-231 R4-251 I26-211 (2B-2B) (JOJt)
<br />Fonn Approved.
<br />_ , , - . OMB No. 2040-0004
<br />Approval expires 05=31-9Bp
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAq WIn1 THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY TELEPHONE DATE
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<br />i :IC FIa YCi A•Il ~~$ INQUIRY OF THOSE INDNIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPON
<br />E THE SUBMITTED IN SIBLE FOR OBTAINING
<br />FORMATION IS TRUE,
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<br />anagEr PENALTIES FOP SUBMITTIN G FALSE INFORMATION, INCLUDING
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<br /> POSSIBILITY OF FlNE AND IMPR ISONMEM. SEE 10 U.S.C. 9 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED 4 1319. (Penett/as under Brass smrures may Include fines up m 510,000 erM n
<br />me+lmum lmpdsmmenl of BeMeelrBmonlhs end5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EFTA Form 3320-7 (OB-95) Previous editions may not be used. ^ ^(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ O , ., ,r 1 n p (1 p 1 'T- L ~,' 0 PAGE OF
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