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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ
<br />DISCHARGE MONITORING REPORT (OMR;
<br />(2-161 (th 9)
<br />•'T99271ti4 '1l9 +
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ' ~ L TO ' ' " ' ~
<br />(2621) (22-231 (2L25) (2&2l) (28-28) (30)1)
<br />Form Approved.
<br />„ q ~ ~ .. OMB No. 2040-0004
<br />(,, n ~ ~ , u l Approval expires OS-31-98
<br />NOTE: Reed Instrucllons before completing this form.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERnFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BARED ON MV ~ TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL S IMMEDIATELY RESPON SIBLE FOR OBTAINING
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<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTIN E THE SUBMITTED IN
<br />I AM AWARE THAT TH
<br />G FALSE INFORMATIO FORMATION IS TRUE,
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
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<br />Form 3320.1 (09-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ A ~ ,. ~ 2 n T ~ It ~ .~-1 ~ ~,~ PAGE OF
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