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PERMITTEE NAME/ADDRESS ~
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />PARAMETER. QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY
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<br />MEASUREMENT
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<br />NAMElTITLE PRINCIPAL EXECUTIV OFFICER I certify under penalty of law that this document and all attachments were T ELEPHON E DA TE
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<br />~ prepared under my direction or supervision in accordance with a system designed /J /f
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<br />to assure that qualified personnel properly gather and evaluate [he information
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<br />or those persons directly responsible for gathering the information, the information ~
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<br />~~ submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ~/ ~~~ ' ~ ~ ~ `
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<br />ED OR PRINTED I am aware that [here are significant penalties for submitting false information, /
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<br />COMMENTS r,ND EXPLANATION OF ANY VIAI including the possibility of fine and imprisonment for knowing violations.
<br />i,T1ANS IRofcrnnrc ~u ~»~i.-....e..f~ r,e.et OFFICER OR AUTHORIZED AGENT AREA
<br />CODE NUMBER YEAR M DAY
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. = z • -• •7~•+~}S?1S -(1$ fll'tr:f(JI111. PAGE _j
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