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<br />NATIONAL POLLIJTAM DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. - ..
<br />DISCHARGE MONITORING REPORT (OMR~ OMB NO. 2040-0004
<br />~-'s! !'r- s/ • ( , "„ Approval expires OS31-98
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<br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDER PENALTY OF
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<br />,~ V\ QS INQUIRY OF THOSE INDMOUAL
<br />THE INFORMATION, I BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE
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<br />ACCURATE AND COMPLETE ,
<br />1 AM AWARE THAT THEAE ARE SIGNIFICANT
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<br />4 POSSIBILRV OF FlNE AND IMPR ISONMEM. SEE 18 U.S.C. 4 1001 AND 33 U.S.C. SIGNATURE OF P INCIPAL EXECUTIVE
<br />TYPEDO PRINTED meamum~resmment olbenree n6mmNU ruttl SUtla fines up ro f1o,000 entl ar
<br />p YaersJ OFFICER OR HORIZED AGENT NUMBER YEAR M DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
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<br />EPA Form 3320-7 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) p 00U I / 9 9 0 S 13-114 0 PAGE 1 OF
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