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PERMITTEE NAM DRESS{Include NATIONAL POLLUT ISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> Facility Name/Loeat fferent)' DISCHAR ONITORING REPORT(DMR) M,8 No.2040-0004
<br /> `=L;�,•,y��_,`_--- 2- 17-19 r• -- - _ Approval expires9-30-85
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<br /> (3 Card Unly) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION FREQUENCY
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY ...MINED TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INPOR MATION SUBMITTED HEREIN AND EASED
<br /> _ _ ON MY INO UIRY OP THOSB INDIVIDVALS IMMEDIATELY RESPONSIBLE FOR
<br />, •��1'.I \�•� . /.'. ` is\:� ).,~` OBTAIN INO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION
<br /> IS TRUB, ACCURA TB AND COMPLETE. I AM AWARE THAT THERE ARE SIG•
<br /> NIFI C ANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br /> THE POSSIBILITY OF FIN. AND IMPRISONMENT. SEE is U.S.C. g ISSI AND SIGNATURE OF PRINCIPAL EXECUTIVE '• 3 t,' « ;!»i '{
<br /> 33 u.s.c. g ,3Is. (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTED andJor maximum imprisonment ofbetween 6 months and 5 years) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br /> CODE
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> 1
<br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTIL SUPPLY IS EXHAUSTED.
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