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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEA O..- DAY.
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<br />Form Approved.
<br />OMB No. 20,40-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER i certify under penalty of law that this document and ell attachments were ~ ,s'~ TELEPHONE DATE
<br /> prepared under my direction or supervision in accordance with a system designed ~ ~\;
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<br />inquiry of the person or persons wha manage the system
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />TYPED OR PRINTED l am aware that there ere significant penalties for submitting false information,
<br />including the possibility of tine and imprisonment for knowing violations. OFF CER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
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<br />COMMENTS AND EXPLANA I wlv ur wrv Y vwL.A I Iurvs fHererence a-- arracnrnents Here/ e ! t _ ~`
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<br />' CJw °.~.;-:~F`~~1Si•1rS'a•'~-~ $Tt%fbITTI. PAGE ~OF
<br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used ~ ~r
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