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PERMITTEE NAME/ADDRESS (Include Facility Natne/Location if Different)
<br />NAME
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<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) , OMB No. 2040-0004
<br />tritDISCHARGE MONITORING REPORT (DMR) ,,:{.y, 1\tfi,.°r
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<br />YEAR MO DAY YEAR MO DAY
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<br />NOTE: Read Instructions before completing this form.
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<br />NAMEITITLEPRINCIPALEXECUTIVEOFFICER Icertifyunderpenalq- oflawthatthisdu<nmentandall attachments were
<br />TELEPHONE
<br />DATE
<br /> prepared under my direction or supervision in accordance with a system designed _
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<br />_ to assure that qualified personnel properly gather and evaluate the information
<br />uiry 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 z
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<br />?a submitted is, to the best of my knowledge and belief, true, accurate, and complete. SI ATURE OF PRINCIPAL EXECUTIVE
<br /> t am aware that there are significant penalties for submitting false information,
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<br />/OFFICER OR AUTHORIZED AGENT
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<br />COMMENTS AND hXFLAINAIIUN Ut- ANY VIULAIIUNb #rrererence au arracnmenrs nerej
<br />3F 1 •1 t,...a:`t•" L '-.' 31 ..?5...: f> ?.'. t rMT T fAIAPreO ""OR "1 O-°4r`k a 2--'---Ig 05RE-C IF EVENT S$104..r2.:. 1` TO 551,3.R'SN OF PROOF IRE,21U RI'E?,.L:?AI f S IM
<br />t-'tN Y. 3. _. ANY AD0Y nf.:FZts=L Ir'A'A SHALL PE SUPPL YED TO THE DI'V ',e.1ION W): i I" IN k•0 i CURS.
<br />rm. PAGE F
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. w? lCe't'4fo1
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