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PARAMETER'
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<br />(62 -63)
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<br />NAME /TTTLEPRINCIPAL EXECUTIVE OFFICER
<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. I .1001 AND
<br />33 U.S.C. t 13%. (Penalties under these statutes may include fines up 1'o $10,000
<br />and or maximum lmprlwnmentof between 6 months and 5years.)
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<br />TELEPHONE -
<br />- DATE
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<br />_ SIGNATURE OF PRINCIPAL ECUTIVE
<br />- OFFICER OR AUTHORIZED AGENT
<br />J� CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED
<br />PERMITTEE NAME/A SS /Include
<br />Facility Name /Locaun •nt)
<br />NAME E+ a l _c uTicu j = _,..
<br />ADDRESS ('(SCI eTY __E C12 1.AA . ,
<br />' ekt ' .--� <.
<br />FACILITY _ - -- _ 0 __ '
<br />LOCATION
<br />- " ,F ROM
<br />EPA Form 3320 -1 (Rev. 9-88) Previous editions may be used.
<br />AT;I C t,hl3 STF.V 0 1�, FhLSIDF.A'! '
<br />r:
<br />NATIONAL POLLUTA HARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHAR NITOR NG REPORT (DMR)
<br />(2 -16 (17 -19)
<br />ronoo0213
<br />YEAR
<br />PERMIT NUMBER t
<br />MONITORING PERIOD
<br />0014 A
<br />DISCHARGE NUMBER
<br />MO DAY - I YEAR MO DAY
<br />TO 91 / 9 30
<br />(20 -21) (22 -23) (24 -25) . (26 -27) (28 -29)
<br />(30 -31)
<br />COMM ENTAND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />IF NO — DISC t4RGr. OCCURS tiP0RT'. "$0 DISCHARGE ". JILE AND GREASE; SEE FOOTNOTE F/.
<br />(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
<br />pproved.
<br />o- 2040 -0004
<br />F — FINAL Approval expires 6 -30 -91
<br />STORi7WAT ER_DISCHAF;,E
<br />1
<br />C i - •
<br />MINOR (SUER. liC) '?:NTIIS
<br />NOTE: Read instructions before completing this form.
<br />0 009 0/ 900 81 0 -140
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