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<br />NAME/TITLE PRINCIpACEXECUTIVE OFFICER ',.:;
<br />1 CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
<br />AND AM FAMILIAR WITH THE INFORMATION-SUBMITTED HEREIN; AND BASED
<br />C OVITAINIV2 ' 14 ?NFRIJ,2SAI,I)NND.IYISVOLEsvmtEEDI:JEVAEPIC,Sti
<br />'
<br />IS TRUE, ACCURATE AND COMPLETE: I AM AWARE THAT THERE -ARE.siG-
<br />NIFICANT PENALTIES, FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />: 1 i E p s 1 IS L up i l 3 - 7 o r e P a l tl A u N e r i m P R 1 S O ta M I E NI 1: , SEE 18 U.S.C: -§ 1001 1 AND
<br />es may Include fines to $0,000
<br />and ormaximum imprisonment of between 6 months and 5 Years.) '
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<br />i SIGNATURE OF PRINCIPAL ECUTIVE
<br />• OFFICER OR AUTillORIZED AGENT
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<br />AREA
<br />CODE
<br />-. NUMBER :...
<br />YEAR
<br />MO
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<br />PERMITTEE NAME' SS (Include , .. !-
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<br />A rTN: D STEvENSOD, PRESIDENr t,...! ae,
<br />- 0 (20-21) (22-23) (24-25) .3 ,-..: '(26-27)
<br />EPA Form 3320-1 (Rev. 9-88) Previous editions may be used.
<br />NATIONAL POLLUT
<br />• DISCHA
<br />(2-1
<br />Ca____ .3
<br />PERMIT NUMBER
<br />CHARGE ELIMINATION SYSTEM (NPDES)
<br />)NITORING REPORT (DMR)
<br />(17-19)
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<br />i• MONITORING PERIOD
<br />(REPLACES EPA FORM T40 WHICH MAY NOT BE USED.)
<br />004 A
<br />DISCHARGE NUMBER
<br />(28-29)
<br />(30-311-
<br />COM M ENLAN D EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here) •
<br />IF NODISEARtE OCCURS REPORT . DISCHARGE".: OILE AND GREASE; SEE FOOTNOTE Fl.
<br />Approved.
<br />F - FINAL No. 2040-0004
<br />STORNWAT ;EARGE APP"Val eXPIreS 6.3"
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<br />pli)ion (suBF wc),-: •NRIFils•
<br />NOTE: Read in before completing this form.
<br />00089/900810-1402
<br />PAGE OF
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