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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES)
<br />DISCHARGE MONITORING REPORT (DMR;
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM r'' '> TO '- `- -
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<br />Forth Approved.
<br />. , „~ „ OMB No. 2040-0004
<br />Approval expires 131-98
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<br />NOTE: Read Instructions before completing this lorm.
<br /> (3 Carci Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-61) (38-48) (4&53) 54-B7 EX OF TYPE
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<br />NAME/TfTLE PRINCIPAL EXECUTVE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF
<br />ILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
<br />IN
<br />AND BlSED ON MY TELEPHONE DATE
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<br />(:(=Tlui Lj MI))S INQUIRY OF THOSE INDNIDUAL
<br />THE INFORMATION, I BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
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<br />I ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFlCANT
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<br />I PENALTIES FOR SUBMITTIN G FALSE INFORMATON, INCLUDING THE
<br /> POSSIBILfrV OF FINE AND IMPR ISONMENT. SEE 1B U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED 5 1319. (Penettlet antler Ness statutes may IncWtle ones up M Ef0,000 entl ar
<br />meumum lmpnsonmerx of beMwenBmarrths entl5yms.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
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<br />COMMENTS AND EXPLANATION OF ANY woLA l IUrv5 (Hererence an aDacnmenls here)
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<br />EPA Form 3320.1 (08A5) Previous editions may not be used. (REPLACES EPA FORM T~0 WHICH MAY NOT BE USED.) ~ „ T ~ F ~ 9 , „ ,r T ~_ t ~ D ;: PAGE T OF
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