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PERMITTEE NAMElADDRESS (include Facility Name/Location if Different)
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<br />DISCHARGE MONITORING REPORT (D R)
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<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER [certify under penally of law that this document and au attacbments were
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<br />d (-~ TELEPHON E DATE
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<br />prepared under my direction or supervtswn m accordance w~[ I
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<br />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 l ~
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<br />true
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<br />, SIGNATURE OF PRINCIPAL EXECUTIVE /~27 `" '
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<br />TYPED OR PRINTED I am aware that there are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment [or knowing violations.
<br />OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a-- arracnmenrs nereJ
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ~~! ~~i~'jj'j~.~~~,,,~''4=~}:~d~- PAGE ^OF -
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