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PERMITTEE NAME/ADDRESS paN,d. FuA~ry Nma/Gocaum,JDiOrrm)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESJ
<br />DISCH1 R6E MONITORING REPORT IDM9l
<br />PERMIT NUMBER DIBCH/JIGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM y v i ~' TO -
<br />,vP-PaI ne-9AI U6.27I UR-291 /30.3!1
<br />Form Approved.
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<br />Appro~d xpires GS-31-98
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY ExAMINED MID / TELEPHONE
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; PND BASED ON // DATE
<br />~ MY INQUIRY OF THOSE INCIIVIDUALB IMMEDIgTELY RESPONSIBLE FOR /
<br />1 BELIEVE THE SUBMITTED INFORMATION IS /
<br />~I\1 L OBTAINING THE INFORMATION
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<br />{ , SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING _ ~ %
<br />E T L THE POBBIBILITY OF FINE AND IMPRISONMENT. SEE 1 B U.S.C. 1 1001 AND 3a
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<br />OFFICEq OR AUTHORRED AGENT
<br />CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS IRererence s// ettecnmenrs Here!
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<br />EPA Form 3320-t 108-951 Previous editions mey be used. (REPLACES EPA FORM T-00 WHICH MAY NO BE USED.1 ~ AGE OF
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