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�iCRMITTEE NA--E/ADDRESS flnclude NATIONAL POL NT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> FacilityNamefL, ifdifferent)i D►SCH E MONITORING REPORT iDMR) OMB No.2040-0004
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<br /> YEAR M O D A V YEAR M O D A Y
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<br /> (20.21 (22.23) (24.25) (26.27) 28.29) (3o-?1) NOTE: Read instructions before completing this form.
<br /> • I - (3 Card Only) QUANTITY OR LOADING (4 Card Only) A QUALITY OR CONCENTRATION FREQUENCY` PARAMETER }, (46.53) (54.61) (3845) (46.53) (54.61) NO. OF SAMPLE
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<br /> EX ANALYSIS TYPE
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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 FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br /> �1( 11 r•�F�• ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY REE►ONSIB L{ FOR
<br /> M O�AI j��r^'1`� • • OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORATION \j /���\�+( J 1 �'/�,'�
<br /> IS TRUE, A E CCURA M
<br /> TE AND COMPLETE. I AM AWARE THAT THERE AR SIG-
<br /> h - - NIFIC A NT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br /> THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 19 U.S.C. 1 I001 AND
<br /> r r l\ as U.s.e. 9 131P. (Penalties under these statutes may include fines up to$10,000 SIGN AT41RE OF PRINCIPAL EXECUTIVE
<br /> TYPED OR PRINTED I and)or maximum imprisonment of between 6 months and 5 years.) - OFFICER OR AUTHORIZED AGENT AREfA CODE NUMBER YEAR MO DAY
<br /> COMMENT AND
<br /> �+EXPLANATION
<br /> hO/F ANY VIOLATIONS (Reference all attachments here)
<br /> lr, �71.) L�r�iJsL�1H/aj�Ga.' t1;y4'l..iU!t:/ t'.i:f'L,",I 11'... I� _ ..11 v �f'sl.tltM 1 f'Iil if•1.I ]. = tL �.. ! - ''1,t..Ll�i:. i�� `� �. •
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<br /> EPkForm 332b-IlRev. l'`-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTIL SUPPLY IS EXHAUSTED. 1 f
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