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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ijDifferent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER ; ' ._. ~-' T p.#y; _ ~(.),c,~: ,
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<br />NAME/TITLE PRINCIPAL EXECU V OFFICER I certify under penalty of law that this document and all attachments were
<br />// T ELEPHON E DA TE
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<br />submitted is, to the best of my knowledge and belief, [rue, accurate, and complete.
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<br />SIGNATURE OF PRINCIPAL XECUTIVE y
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<br /> am aware t
<br />at there are significant penalties for submitting false information,
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER
<br />YEA
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<br />EPq Form 3320-1 (Rev. 3/99) Previous editions may be used. t.~0 ~ ~` _ ._, ~h1~kS U ~~~~~~ PAGE _,t OF
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