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f PERMITTEE NAME/ADDRESS pnclude Paci/Iry Nmnr/Jncarion iJDi$erem)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />DISCNARGE MONITORING REPORT (DMfl~
<br />l2-151 r1 ]- 91
<br />^l'+3?71riI '1.'IR D
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ' ' I - TO ' ' ~ -
<br />(2421) (12231 (1a25) (28-2]) (18-29) (3031)
<br />Form Approved.
<br />~„ OMB No. 2040-0004
<br />+ ~ Approval expires 05.31-98
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAA Wmi THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY ~ TELEPHONE DATE
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<br />RICG INQUIRY OF THOSE INDNIDUAL
<br />THE INFORMATION
<br />I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE
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<br />~nvircnr+~ntal A,ianagPr ,
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING ,
<br />I AM AWARE THAT THERE ARE SIGNIFICANT
<br />FALSE INFORMATION
<br />INCLUDING THE
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<br />370-870-2712 ~ ~ ~^
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<br /> POSSIBILnY OF FINE AND IMPRI
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<br />(Peneltles under these s ,
<br />SONMENT. SEE 16 U.S.C. 51001 AND 33 U.S.C.
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<br />NUMBER
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<br />EPA Form 33261 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ., ~ t , ~ / ~ i n (l l ~-1 S "''7 PAGE ~ OF
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