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<br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />YEAR MO InTO
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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
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and comp SIGNATURE OF PRINCIPAL EXECUTIVE A` 4 [ V
<br /> I am aware that there are significant penalties for submitting false information, ORIZED AGENT AREA
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. `
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