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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEA MO DAY„ YEA.. 0 DAY
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<br />Form Approved.
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certify ender penalty of law that this aocoment and all attachments were ~'~- i TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br /> to assure that qualified personnel properly gather and evaluate the information -~ `111jjj
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<br />submitted. Based on my inquiry of the person or persons who manage the system,
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE _
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<br /> I am aware that there are significant penalties for submitting false information, ORIZED AGENT
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<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFI
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<br />CrO>~MMENTS~rAND EXPLAN7ATION~e OF fANY VIOLATIONSy~(Reference all~attachAmlents here) _a tr 2 Ac t T~ rryr~ 1~ ~+ ~1 p~p~ 11~ ~ )Sr tip ~^*~^
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ~~~-~r~~"~f`4T~iiscs°a'4=panti'~OTIri. PAGE OF
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