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PERMITtin NAME/ADDRESeI.(/nrlllde! ATIO AL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDEJ) lE«m AQQfOYEd
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<br /> 4 (DISCHARGE MONITORING REPORT(DAIR)
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<br /> ( Card Only) QUANTITY OR LOADING (+ Card Only)" QUALITY OR CONCENTRATION 3 -' FRfOUfNCLOAMPLE
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTYOF LAW THAT IHAVE PERSONALLY EXAMINED _ _ _ - `-' - TEL - - O A TE
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED _ r 1
<br /> //q�{ ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> 7/ R.?/'��l/ %� OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION % J ^ 1_1� T C 11
<br /> V Y IS TRUE ACCURATE AND COMPLETE 1 AM AWARE THAT TN RE ARE SIG I/ FFee _ 1 ` L 1 • J.
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION. INCLUDING -
<br /> �Y 1 / THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IS USC 1 IOOt AND •61 ATURE OF�PRINCIPAL:EXECUTIVE -
<br /> 33USC 11319 IP.m NR. und,, Ih.N Jmmr.. m -II/I uR m [I2111n _ _ _
<br /> TYPED OR,10RINTED I ardmma.imum lmPrunnmrnr.r/h.mvn6m.mlhw and.l...... "� _
<br /> -OFFICER.OR AUTHORIZED AGENT NUMBER YEAR MO DAY
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<br /> COMMENT AND EXPLANATION OF ANY'VIOLATIONS (Rr/erenre all ulluchnients here) _ `- `T I _ s ^_ ,; .� ; _
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<br /> EPA Form 3320.1 (Rev. 10.79)uNnI SUPPLITION Y IS TO BE>USED IRIPLACKS EPA FORM-T-40 WHICH MAY NOT BE USED.) 1:r v%t�'+v.�G PAGE OF
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