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PERMITTEE NAME/ADDRESS (IncludeFaciliryName/Location ifDi~erent)
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<br />ADDRESS LLJI`~l~i~.).~"i.J C~,t1~1'i"f)I~ 1'~i.,"'.E._
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTI E FFICER I certify under penalty of law that this document and all attachments were T ELEPHON E DA TE
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<br />~.v / 1 7:I~ ~ V ~. ~ prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate [he information
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<br />}~ submitted. Based on my inquiry of the person or persons who manage the system,
<br />or [hose 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 XECUTIVE ~
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<br /> am aware t
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<br />ere are significant 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
<br />MO
<br />DAY
<br />l~A 111111A CLITQ ALIr1 CYDI ANATIAN AC AIa1V \/IAI ATIA4IQ /~..f........... ..II ..sa~~L ~~.~a_ CODE
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be rased. r, +,.y r;,, PAGE OF
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