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<br />LOCATION
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<br />n Ar1oNAL FoLLUrAnr D1lcnwnor ELIMINATION •YST[M (NPDEJI
<br />DISCHARGE MONITORINO REPORT /DMRI
<br />116 `` 1~
<br />PHRMIT NUM S[R oIAC.ARCE NursEw
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO OAY
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<br />~ I` Form Approved.
<br />l ' ' ' " ~' ") OM9`No.12040-0004,
<br />+ ~ 1 ~ ^ ~ Approval Expires 6-30.91.
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<br />NAM[/TITLL PRINCIPAL [%[CUTIVE OFFICER I CEIRIFY unOER FEnALTr OF LAw THAT I NAV[ RERBOnALLV EXAMINED
<br />ANO 11M FwMIL11R WITH TM[ IMFORMATION SUBMITTED HEREIN 11ND BASED TELEPHONE D A T E
<br /> ON MY mO111PY OF TNp.'E INDVIDUAL6 MMfgAT[LY RESPONSBLE iOP
<br />06TwInIfIL TN[ InfORMATIO!1. I BELIEVE THE SUBMITTED INFORMATION
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<br />rNF Po551BILITr Of FINE wnD IMRR50NMENi sE[ IB u5C 1 1001 wND 610HATU RE OF PRINCIP
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<br />GOMMLNT AND E%PLANATION OF ANY YIOLwn ONS Inpornrr un mmrnmrnu nrrrl
<br />AL'PhdtIF1'E LItrITS FOR T:i9 G 5t:'C'f'LEACiL SULILii (WC FL') ;:arLt (.rliY 1F C= i...-Yn, mil'-;In iaLlik I~Yr.'i7 :S
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