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PARAMETER '441111111.11"- QUANTITY OR LOA
<br />QUALITY OR CONCENTRATION
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<br />ANALYSIS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I certify under penalty or law that this document and all attach Dents were
<br />prepared under my direction or supervision in accord:aux: with a systm desagnod
<br />to assuro that qualified personnel properly gather arid evaluate dic inforrriation
<br />..ummit,d. &wed on my Inquiry ar the, poruon or porronn who manase the ryntem.
<br />‘,.. Min..: persons directly remonsible for gathering th e information, the information
<br />submitted is, to the inw of my knowledge and belief, true, accurate, and comphle.
<br />I am au are that there arc significant penalues for submitting false information,
<br />,ncluJing the possibility °cline and hupnsonment for knowing violauons.
<br />TELEPHONE
<br />DATE
<br />3(33
<br />1 7 2/
<br />11
<br />2_
<br />2 2-
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<br />/ i _
<br />Vi 1 15
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<br />VI 11
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />OFFICER OR AUTHORIZED AGENT
<br />SR
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED
<br />PERMITTEE NAME/ADDRESS (inchide Differenl)
<br />NAME
<br />FACILITY •--; • .
<br />LOCATION
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.
<br />FROM
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER
<br />YEAR
<br />MO
<br />MONITORING PERIOD
<br />DAY
<br />TO
<br />DISCHARGE NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />NOTE: Read Instructions before completing this form.
<br />,.• .4.1part. form.
<br />Form Approved.
<br />OMB No. 2040-0004
<br />PAGE 3 OF .3
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