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<br />NATIDNAL PQLLUTANT OISCNMGE ELIMINATON 9VBTE1.1 ((NPDESI
<br />DISCHARGE MONITORING REPORT /DAlRI
<br />1-161 /7-191
<br />PERMIT NUMBER DISCNMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR . MO DAY ~- YEAR MO DAV
<br />FROM TO~ ~ 31
<br />!76211 31 111.261 ~:~ !1627/ 128-191 136311
<br />Form NApproved.
<br />:~clrn 6 71v-~lw TV QI.lB E-°{{2a4~"0004~r.
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<br />M653 !51-61 _ 38-16 ~ !1653 !61-67
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<br />161.681 169-701
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<br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I cERn
<br />AM fA fY uHDER PENIUr
<br />uw TNAT I NAVE PERSONALLY ExAMINED MD
<br />MIUM WITH THE INFORMATION SUBMITTED NERDN
<br />MD BASED ON TELEPHONE DATE
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<br />MY INQUIRY OF THOSE INDINDUAL6 IMMEDIATELY RESPONSIBLE FOR , _
<br />{
<br />Rlc,lard Mills OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS /
<br /> TRUE, ACCURATE MD COMPLETE. 1 AM AWME TNAT THERE ME
<br />SIGNIFICAMT PENALTIES FOR SUBMITTING FALBE INFORMATION
<br />INCLWING /f
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<br />environmental :. aaa er ,
<br />THE POSSIBILITY OF FlNE MDIMPRISONMENT. SEE IB U.S.C.11001 MD33
<br />,. 610NATURE OF %IINCI-AL EXECUTIVE ~9]Q $]0-2712 1• 27 np
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<br />TYPED OR PRINTED U.S.C. f 131 e. 61r;W W. Isld~r eN.F Mfuhs nrY MICNW lvys ye ro i IO,OGO
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<br />OFFlCER OR AUTHORIZED AGENT
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Rel'erencs sll ettschmenfs here!
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<br />EPA Form 3320-1 108.951 Previous editions msy be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) U U 1 i C / Y c 1 J u i - 1311 PAGE I OF
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