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PERMffTEE NAME/ADDRESS Qnclude Facdiry Nmndlocalion iJDi$ermq
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<br />NATIONAL POLLUTANT DISCHARGE EUMINATON SYSTEM (NPOES)
<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 9~ )~ ) 1 TO ^ n n T 1
<br />Ro-zU (zz-x31 R4zs1 pbz~) (zazs) (3(131)
<br />Form Approved. I
<br />T ^ , OMB No. 2040-0004
<br />Approval expires 0631-88
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<br />~NOTE: Read Instructions before'Campleting thls form.
<br /> (3 Cerd Ony) QUANTITY OR LOADING (4 Cerd Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER OB-53) 54-81) (3B<5) (4653) (5461) EX OF TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSONALLY E%AMINED AND
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE,
<br />'.I Gj~c Yi: i.".j jj:; ACCURATE AND COMPLETE. I AM AWARE THAT THERE ME SIGNIFlCANf
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<br />'IV It'OnPI?11. t.7j i'.7aT17Ql' CL
<br />PENALTIES FOR SUBMITTING FALSE INFORMATION, I
<br />NG THE
<br />POSSIBILfTY OF FlNE AND IMPRISONMENT. SEE IB U.S.C.41001 AND 33 U.S.O
<br />SIGNATURE OF PRINCIPAL EXECUTVE
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<br />TYPED OR PRINTED § 1318. (Pere/lias urMw /tease stetlrtes mey /nolutle lines up b ft0.000 entl a
<br />mex/mum impnsonmerx o/heMeen6monlhs entl5yeers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLA710N5 (Relerence an alrecnments nereJ
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<br />EPA Form 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) n ~,1 n ^ /,t ~ r, ^_ 1 ~ r PAGE OF
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