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<br />NATIONAL POLLUTANT DISCHARGE ELMINATON SYSTEM MPDESJ FOrm Approved.
<br />DISCHARGE MONITORING REPORT (OMR~
<br />14 OMB ND. 2040-0004
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<br /> Approval expires 0531-98
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<br />PARAMETER (46-53 5461) (38-45) 4E53 (54-61) EX OF TYPE
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<br />NAME/TRLE PRINCIPAL E%ECUTNE OFFICER I CERTIFY UNDER PENALTY OF L
<br />AM FAMILIAR WRH THE INFORM AW THAT I HAVE PERSONALLY EXAMINED AND
<br />ATION SUBMITTED HEREIN
<br />AND BASED ON MY TELEPHONE DATE
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<br />T~IChef 4 •'UIIe INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE.
<br />T S IMMEDIATELY flESPONSIBLE FOR OBTAINING
<br />E THE SUBMTTED INFORMATION IS TRUE,
<br />1 AM AWARE THAT THERE ARE SIGNIFlCANT .
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<br />~f7VICClT1"C~lti]I Bh3 T73 2F IES FOR SUBMITTING
<br />PENAL FALSE INFORMATION, INCWDING THE 97O-S7O-272 7 Z6 ~9
<br /> POSSIBILRY OF FINE AND IMPRI SONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> § 1318. (PensHiav antler Noce arehrtas may Irlclutle Hriaa up b 510,000 entl d
<br />TYPED OR PRINTED maximum lmpnsrnment or6elxeenemonW entls years.) OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
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<br />EPA Form 3320.1 (08-95) Previous editlons may not be used. (REPIACES EPA FORM T~0 WHICH MAY NO7 BE USED.) PAGE OF
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