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<br />NATIONAL POLLUTMT DIBCNMOE ELIMINATION SYSTEM INPDESI Fonn Approved.
<br />DISCHARGE MONITORING REPORT lOMR) , _ ~ - - .--,OMB~No: 2040-0004F s
<br />l7-I6l (17-191
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<br />PARAMETER 13 Grd Onlrl QUANTITY OR LOADING !I Grd oelTl QUANTITY OR CONCENTRATION ND. FREQUENCY SAMPLE
<br /> 146-531 1546E1 139-461 H6-5J 154611 EX µY TYPE
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<br />NAMElTITLE PRINCIPAL EXECUTNE OFFICER I cERnFr UNDER PENUrr GF LAw TNAT I NAVE PERSONALLY ExAMINED MD
<br />AM FAMIUM WITH THE INFORMATION BUBMITTED HEREIN; MD BASED ON TELEPHONE DATE
<br /> MY INDUIRV OF TNOSE INDIVIDUALS IMMEDIATELY REBPON9IBLE FOR
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<br />I~IchEYG 1'11115 OBTNNING THE INF011MATON, I BELIEVE THE SUBMITTED INFORMATION 19
<br />TRUE, ACCUMTE AND COMPLETE. I AM AWME TNAT TNERE ME
<br />FCMi PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCIUDINO
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<br />1=IlV IYGI'1E1211 te1 , ~E 1'18 r3eC ,
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<br />THE POSBIBILITV OF RNE MD IMP1e9oNMENT. BEE to U.S.C. E t00t MD 77
<br />~BIONA7URE OF PRINCIPAL E%ECUrrvE (giG ) 87C-2712 E z
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<br />TYPED OR PRINTED nMwnr..l.e.e inF+raNlm.nr or anr.Fn sntoon.wsTw.) OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLA71aN5 lrrsrersnce an errecnmenu nersl
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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.1 ~ ,.., ~, ~ ~„ „ !, It ~ ~ - ~ ,I rt I, PAGE I OF
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