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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I certify under penalty of law that this document and all attachments were
<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
<br />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 />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />I am aware that there are significant penalties for submitting false information,
<br />including the possibility of tine and imprisonment for knowing violations.
<br />,
<br />1 ,
<br />---- 0, A,
<br />TELEPHONE
<br />DATE
<br />' / ' ...)
<br />` ,," r -..../
<br />f
<br />071'
<br />72:--Ae: 14 ---.- eicl . . .S
<br />v ::::7%.416,
<br />....„ ...
<br />SIGNATUR E OF'PRINcIPAL EXECUTIVE
<br />c AUTHORIZED AGENT .,_.
<br />AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED
<br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location tfDtffere,tt)
<br />ADDRESS'',
<br />LOCATION . , .
<br />FROM
<br />YEAR
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />" r
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER
<br />MO
<br />MONITORING PERIOD
<br />DAY
<br />TO
<br />YEAR
<br />J
<br />DISCHARGE NUMBER
<br />MO
<br />3 ,
<br />DAY
<br />NOTE: Read Instructions before completing this 'form.
<br />4-paxtform.
<br />Form Approved.
<br />OMB No. 2040-0004
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