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PERMITTEE NAME/ADDRESS (include Facility Name/Location if Different)
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<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<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 I certify under penalty of law that this document ana all attachments were --~,
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<br />! TELEPHONE DATE
<br /> prepared under my direction or supervision in accordance with a system designed ~.e.----.
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<br /> to assure that qualified personnel properly gather and evaluate the information
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<br />submitted. Based on my inquiry of the person or persons who manage the system,
<br />or those ersons direct) res onsible for atherin the information, the information ~
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<br />'.'O~,` ~~~ ~~ submitted is, to the best of my knowledge and beI ef, true, accurate, and complete. ~
<br />h SIGNATURE OF PRINCIPAL EXECUTIVE Iv DtrJ t ~ ~ ©~ Vim'
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<br />TYPED OR PRINTED I am aware t
<br />at there are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for 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 all attachments here)
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<br />EPA-Form 3320-1 (Rev. 3/99) Previous editions may be used. ~~~°~yG~tr~1ThiS-s`a`~4-~afC'~bYI11. PAGE cOF
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