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PERMITTEE NAME/ADDRESS (Include FacilityName/LocationifD~erent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) y OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL IX C TIVE O FFICER t certif under
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL `
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<br />TYPED OR PRINTED
<br />I am aware that there aze significant penalties for submitting false information, EXECUTIVE !
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<br />COMMENTS AND EXPLANATION OF ANY VIOL
<br />including the possibility of fine and imprisonment for knowing violations.
<br />ATICINR /Ruforcnrn ~f~ ~ts~..ti...es~ ~....,.~ OFFICER OR AUTHORIZED AGENT 'AREA
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<br />mpletmg this form.
<br />FREGUENCYI SAMPLE
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. lit.) ~ flc. , C} ~}I~Si 3 4 ~~ PAGE ~ OF r
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