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PERMITTEE NAME(ADDRESS (InchrdeFaci7ihr Name/Location ifD~errnt)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR) ~ ~ ..J~
<br />PERMIT NUMkBER DISCHARGE t~lUMBER ~ ~ , t ,
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL E3tECUYIVE OFFICER I certify under penalty of law that this document and all attachments were --
<br />~ TELEPHONE DATE
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<br />- or those persons directly responsible for gathering the information, the information r
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<br />i ~ SIGNATURE OF PRINCIPAL EXECUTIVE ~77G' ~ t' % "`~ SL ,-' C,~` ~ /~ Cj ~'iC
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<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
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<br />NUMBER
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<br />EPA Form 9320-1 Rev. 3/99 Previous editions ma be used. „ r. ;_ 4 p_ PAGE OF
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