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PERMITTEE NAME/ADDRESS (7ncludeFacilityName/LocationifD~erent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />PARAMETER
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<br />NAME/TITLE PRINCIPAL IXECUT V OFFICER 1 certify under penalty of law that this document and all attachments were T ELEPHON E
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<br />prepared under my direction or supervision in accordance with a system designed DA TE
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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, the information
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<br />. submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />I SIGNATURE OF PRINCIPAL E CUTIVE ~ _ ~ ~
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<br />YPED OR PRINTED am aware that there are significant penalties for submitting false information, I
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<br />COMMENTS AND EXPLANATION OF ANY VIOL
<br />including the possibility of fine and imprisonment for knowing violations.
<br />ATIONS /Referenr_e afl ariar_hmontc hora- OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
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<br />EPA Form 3320-1 (Rev. 3/99) Previous edifions may be used. ,'1{:? ~ r-i~l ;. r" a~~~~~ A 4-~~jFA1T11 PAGE ,_, OF
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