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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifD~erent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (MPDES) Form Approved. -
<br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-000a
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<br />NAMElTITLE PRINCIPAL IXECUT VE FFICER 1 certify under penalty of law that this document and all attachments were T ELEPHONE DATE
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<br />r prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information
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<br />~ submitted. Based on my inquiry of the person or persons who manage the system,
<br />or those persons directly responsible for gathering the information, [he information
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<br />~~ submitted is, to the best of my knowledge and belief, tine, accurate, and complete.
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<br />h SIGNATURE OF PRINCIPAL EXECUTIVE /~
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<br />TYPED OR PRINTED am aware t
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<br />ere are significant penalties for submitting false information,
<br />including the possibility of tine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. PAGE OF
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