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<br />NATIONAL POLLUT' ~ISCHMOE ELIMIMATON BYSiEM /NPOES) Form P^nrOVOd.
<br />DISCNA' NONITORINO REPORT /DMR) OMB 2040-0004
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<br />PARAMETER !3 Grd Ontyl QUANTITY OR LOADING !I Grd Onryl QUANTITY OR CONCENTRATION ND FREQUENCY SAMPLE
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<br />NAMElTITLE PRINCIPAL E%ECUTNE OFFICER I CFIITFY UNDER PENALTY OF l
<br />AM FAMIDM WITH THE INFO AW THAT I HAVE PERSONALLY E%AMINED MD
<br />RMATION SUBMITTED HEREIN: MD BASED ON
<br />/ TELEPHONE DATE
<br /> MY INQUIRY OF TNOSF INDINDUN.9 IMMEDIATELY RESPONSIBLE FOR
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<br /> OBTNMINO THE INF011MATON, I REDEYE THE SUBMITTED INFORMATION IS
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<br />THE POSSIBIDTY OF RNf MD IMPNSONMFNT. SEE 18 U.S.C. 1 1001 MD JO
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<br />BIONATURE Of PRINCIPAL E%ECUTNE
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<br /> U.S.C. 1 171/. lAaWW, „./,r IArw mamr, m.F hcltl, rw, y ro f 10,000 AREA
<br />TYPED OR PRINTED .nd ornwirn.:l brwrm:.nrwanr..asAw,m,weP..rA/ 'OFFICER OR AUTHORI7ED AGENT CODE NUMBER YEAR MO DAY
<br />GVMMCN IJ ANU tRrLANAIIOn ur ANY VIULAI Wn, lKerMYOC1 en srrecnmenrs Nlel
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<br />EPA Form 3320.1 108-961 Previous editions mey ba used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.1 PAGE OF
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