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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER -,
<br />-
<br />'I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
<br />AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED
<br />ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING-THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION
<br />IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG-
<br />-NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S C. 4 .1001 AND
<br />-33 U.S.C. 1319. (Penalties under these statutes may include fines up to 310,000
<br />11
<br />and or maximum imprisonment of between 6 months and 5 years.)
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<br />' SIGNATURE OF PRINCIPAL EX UTIVE
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<br />. OFFICER OR AUTHORIZED AGENT
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<br />• ATA
<br />CODE
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<br />DENNIS' PRFS ,---
<br />EPA Form 3320-1 (Rev. 9-88) Previous editions may be used.
<br />FROM
<br />NATIONAL POLLUTA
<br />DISCHA
<br />(2-1
<br />co - 1
<br />PERMIT NUMBER •
<br />MONITORING PERIOD
<br />0 a
<br />01
<br />YEAR
<br />(20-21)
<br />MO
<br />(22-23)
<br />CHARGE ELIMINATION SYSTEM (NPDES)
<br />INITORING REPORT (DMR)
<br />(17-19)
<br />DAY
<br />(24-25)
<br />TO
<br />26-27
<br />(REPLACES EPA FORM T.40 WHICH MAY NOT BE USED.)
<br />00 1
<br />DISCHARGE NUMBER
<br />91
<br />o
<br />YEAR
<br />MO
<br />28-29
<br />DAY
<br />30
<br />30-31
<br />F - FINAL
<br />STORMUATER
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all aithchments here)
<br />IF NO DISCHkRGE OCCURS REPORT,"NO DISCHARGE". OIL AND GREASE; SEE FOOTNOTE F/.
<br />-,-)
<br />a i I
<br />1 .
<br />tiiNnri (suan 161C) rATR5
<br />NOTE: Read in before completing this form.
<br />00072
<br />Approved.
<br />lo. 2040-0004
<br />, royal expires 6-30-91
<br />DISCHAF5E
<br />PAGE OF
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