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<br />NATIONAL POLLUTANT DISCHARGE EUMINATON SYSTEM MPOES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMH; OMB NO. 2040-0004
<br />~-'s( r1I- °( ~ ' ~'' ' Approval expires 05-31-98
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDEq PENALTY OF
<br />AM FAMILIAR WITH THE INFORM
<br />TH
<br />N
<br />DUAL LAW THAT I MAVE PERSONALLY E%AMINED ANO - TELEPHONE
<br />ATION SUBMffTED HEREIN; AND BASED ON MY /
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING / ~ DATE
<br />OSE IND
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<br />INQUIRY OF
<br />THE INFORMATION, I BELIEV
<br />~;)CF18 rCI i•..I}IS ACCURATE AND COMPLETE. ///)~
<br />E THE SUBMITTED INFORMATION IS TRUE, // , /
<br />I AM AWARE THAT THERE ARE SIGNIFlCANT +/, (T //i."]]]~ ,' qQ
<br />
<br />PENALTIES FOR SUBMITTIN
<br />~n V i ranrrs'rlte 1 ::.? T _'` f'r POSSIBIUTV OF FINE AND IMPR
<br />G FALSE INFORMATION, INCLUDING THE r370_t~70_271~
<br />ISONMENT. SEE 18 U.S.C. 51001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTNE 77
<br />/ / ~a TJ
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<br />TYPED OR PRINTED g 1319. (PeneMes under mesa srelurea may inclutle /lnes up ro 510,000 end n
<br />maximum rmpdswxnenl of beMSenOmanms end5yeersJ OFFICER OR AUTHOR2ED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence rv( etlacnmenrs Here)
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<br />EPA Form 33201 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) n n t ~ .) ~ ,t n ~ r~, ~ _ T ~ O I PAGE ] OF
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