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PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different)
<br />NAME
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<br />ADDRESS za?liy
<br />FACILITY
<br />LOCATION t. , , li•
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />=GFrs MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />"s.I i /v' 21-3 FROM 1 fUl kl . 1:i TO 4 taw ?
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before completing this form.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br />,44111 ??'
<br />,11
<br />41 to assure that qualified personnel properly gather and evaluate the information
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<br />e submitted. Based on my inquiry of the person or persons who manage the system,
<br />or those persons directly responsible for gathering the information, the information '
<br />r Y submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE 3 .•?-1 ?^
<br /> I am aware that there are significant penalties for submitting false information, AREA
<br /> risonment for knowing violations
<br />f fine and im
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<br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />TYPED OR PRINTED .
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<br />COMMENTS AND EXPLANATIVN UI- ANY VIULAI IUNS (Hererence an arracnmenrs nere/
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<br />'_ i'aA". FOR w0 %'IND -4 HF' yf'L?,i.•D'=.N 0- t.r:`5? ? J: 3'.i
<br />4 ,,r vv ^ i SU'!'€?w„ITT,1 T5 f lHlE w .7 d ON la4 F'y > Est°r } ? S.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. .r f,io o 7 6R?s iI T4-R3't"Ann. PAGE
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