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PERMITTEE NAME/ADDRESS (Include FaciliryName/Location ifD~erent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) ~„ lt~ OMB No. 2040-0004
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL IXECUT VE FFFCER I certify under penalty of law that this document and all attachments were T ELEPHON E DA TE
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<br />/' G• prepazed under my direction or supervision in accordance with a system designed
<br />~ to assure that qualified personnel properly gather and evaluate the information
<br /> submitted. Based on my inquiry of the person or persons who manage the system,
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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.
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE
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<br /> am awaze t
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<br />icant penalties for submitting false information,
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<br />TYPED OR PRINTED
<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
<br />NUMBER
<br />YEAR
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<br />EPA Form 3320-t (Rev. 3/99) Previous editions may be used. t3 ~ ~ :3~ :, t.)~~~~~ ~ 4~f~riri. PAGE ,_~ OF
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