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PERMITTEE NAME 'ODRESS (Include NATIONAL POLLUTP ISCHARGE ELIMINATION SYSTEM(NPDES) orm Approved
<br /> FacllityNatne/Locat' ferent) DISCHAR ONITORING REPORT (DMR) 1MB No.2040-0004
<br /> `-,— '�» 1 • '_----------- 2-. 17-19 Approval expires 9-30-85
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E
<br /> AND AM PA MILIAR WITH THE INFORMATION SUBMITTED HEREIN AND EASED
<br /> L ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> DOT A INING THE INFORMATION, 1 ■ELIEVE THE SUBMITTED INFORMATION '
<br /> 1■ TRUE, ACCURATE AND COMPLETE, I AM AWARE THAT THERE ARE SIG- '
<br /> N IPI CAN PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br /> THE POSSIBILITY OF FINE ANO IMPRISONMENT. SEE n U.E.C. 4 loot AND SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> 33 u.E.c, 0 t.u, (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTED and)or maximum imprisonment of between 6 months and 5 years-) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br />:OMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) CODE
<br />.PA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES CPA t'ORM T-40 NHIC:H t.-,AY NOT Ls-: USED j C;
<br /> UNTIL SUPPLY IS EXHAUSTED. '
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