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PERMTTTEENAME/ADDRESS(n,~tvd.Faraiy,vom~rmm.ifDifferenQ NATIONAL POLLUTANT DISCHARGE ELIMINATION3137EM(NPDES) FonnApproved.
<br />NAME n• f. c c DISCHARGE MONRORINO REPORT (DMR~ OMB NO. 2040-0004
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<br />Approval expires 05-31-98
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIOAR WITH THE INFORM LAW THAT I HAVE PERSONALLY F]UMINEO AND
<br />ATION SUBMnTED HEREIN
<br />AND BASED ON MY TELEPFIOFIE DATE
<br />y INQUIRY OF THOSE INDNIDUAL
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<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
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<br />1 ACCURATE AND COMPLEfE~ I AM AWARE THAT THERE ARE
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<br />PENALTIES FOR SUBMITTING
<br />n/L h •~ ~ f POSSIBILnY OF FINE AND IMPRI FALSE INFORMATION, INCLUDING THE
<br />SONMEM. BEE 18 U.S.C. § 1001 AND 33 U.S.C. Li
<br />IGNATURE pF PRINCIPAL EXECUTR/~ '~ 7 - "17 1 Q
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<br />TY ED OR PRINTED medmum impnsonmerr olSeMee mMas may inclutle lines up ro f10,000 arM or
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence ell efA~chments here)
<br />~. SAY AYEiiAGE IS FICEk~? CC67HIY AVC. DUPIAG F2G]CC FPFC~'IF[. CII F.. Cbt;F - SFE I.~.1.[, F. S.
<br />EPA Form 3320.1 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
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