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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATON SYSTEM /NPDESI Form Approved
<br />DISCHARGE MONITORING REPORT lOMR1 OMB No. 2040,
<br />1-Jd ' 17-f91 ~ ' ~ ~ ~~ APProvd expi{ep 05-3
<br />PERMIT NUMBER DISCMMGE NUMBER f~ _ ; ~ i ,, _ , ~ ~ /~~
<br />MONITORING PERIOD ~ ~ ~ C`/ ~~(
<br />YEAR MO DAY YEAR MO DAY __
<br />FROM ~ . ~ ~1 TO 'j 7 UI~ J ~ ....~. r .~ -,. ~, „~ I I ~ ~ ,
<br />124211 /12-231 !14251 126271 128-291 !36311 NOTE: Reed instructions betora complstinp thin form.
<br />PARAMETER l3 Grd Onlyl QUANTITY OR LOADING !I GTd OnNI QUANTITY OR CONCENTRATION NG FREOVENCY SAMPLE
<br /> 0683 51-81 38-IS 14663 /5a-6fl EX of
<br />13I-371
<br />AnALYSs TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 161~eJ1 /8458) 169-701
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERTI
<br />AM FA FV UNDER PENALTY of
<br />MILIAR WITN THE INFO uw TNAT t NAVE PERSONAUV EXAMINED AND
<br />RMATION SUBMITTED HEREIN
<br />AND BASED ON TELEPHONE DATE
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<br />MY INOUIPY OF THOSE INDINDUALS IMMEDIATELY RESPONSSLE FOR
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<br />~ . p`_ OBTNNING THE INFOIMATION, I BELIEVE THE SUBMITTED INFORMATON IS . ;
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<br />{ TRUE. ACCURATE AND COMPLETE. I AM AWARE THAT TNEAE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />THE POSSIBILITY OF flNE AND IMPNSONMENT
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<br />. SIGNATURE OF P111NgPAL EXECUTIVE :
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<br /> U.S.G. ! t31a. lAtrWIMI ,.N« NrM mtube maY L%'A/4. hw. w ro t Io,000
<br />TYPED OR PRWTED .ne«ma.Amm inplArnlntWbevwlemenlAa rMBPerA/ OFFlCER OR AUTHOpRED AGENT CODE NUMBER YEAR MO DAV
<br />COMMONIS AND [APLANXIIVN VT ANT VIVLN 1IVNJ IneTBlBOCB en eReC/lmenl3 nB/6/
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<br />EPA Form 3320-1 108.951 Previous editions mey be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ PAGE OF
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