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PARAMETER
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<br />S3 + (54-61)
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<br />(3843)'= (46-53) (54-61)
<br />NO
<br />EX
<br />(62-63)
<br />FREQUENCY
<br />- OYSIS
<br />(64 -68)
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
<br />AND AM FAMIUAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED
<br />ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION. I BEUEVE 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 S 18 U. S .C . 4 1001 AND ,
<br />- U.S.C. ;- 1319. (Penalties under these statutes may include fines up to .510,660 '
<br />and or maximum i of between
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<br />T i4 DC I � y �
<br />I "JJJ "'
<br />TELEPHONE
<br />DATE
<br />Brian P,' x},1 1 e , -
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<br />• I SIGNATURE OF PRINCIPAL ECUT
<br />, OFFICER OR AUTHORIZED AGENT
<br />• , $
<br />- TYPED OR PRINT D
<br />r . .-
<br />CODE NU Be
<br />YEAR
<br />MO
<br />DAY
<br />PERMITTEENAME/ SS(Inchde _ i, -
<br />FacilityName/Loco rent) 1 ' � :. ? . . � {
<br />NA '21,, LCI)L SC i1(tGL.d:I1I.3E1
<br />ADDRE CX.JULT-Y_B V_Aili—_— —.
<br />FACILITY — _ — —
<br />LOCATION
<br />:,TTY+: DENNIS' STFVE SON
<br />EPA Form 3320-1 (Rev. 9-88) Previous editions may be used.
<br />•
<br />,p ;a`r i :
<br />T FROM 4i I
<br />YEAR
<br />V f� S'I DE Nei .,, : , f ,,, (2
<br />NATIONAL POLLUT CHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHA 3NITORING REPORT (DMR)
<br />(2- (17 -19)
<br />PERMIT NUMBER
<br />^f!4
<br />DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />MO DAY - YEAR
<br />DAY
<br />-• G I TO 91 U:) 30
<br />) (24 -25) ' := (26 -27
<br />(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
<br />MO
<br />28 -29
<br />30-31
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />tP
<br />IF '•O �`LISCHf,RGE OCCURS REPORT "NO DISCHARGE ". OIL Akio GREASE; SEE FOOTNOTE F/.
<br />F , - FINAL oval expires 6-30-91
<br />S 10Rt19ATE :H Aiii,E _ _
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<br />J _
<br />tiN1OR (Sinn '.:'"�iT
<br />NOTE: Read in B completing this form.
<br />00106 /900810- 1E02
<br />Approved.
<br />No. 2040-0004
<br />PAGE OF
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