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TIT`FTEE NAME/ADDRESS(Include NATIONAL POLLUT-NT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> Facility Name/Lo ifdifferent); DISCH MONITORING REPORTlDMR) OMB No.2040-0004
<br /> NAME_ -1 _AI �r•d `;��!'iL_��.�' +�- --- 17-19 �' — y- (�fI L, - Approval expires9-30-85
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64.68) (69-70)
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED n \ TELEPHONE D A T E
<br /> t AND AM FAMILIAR WITH THE INFORMATION SUBMITTED MITTED HEREIN AND ■Af ED
<br /> `Cy �I}�).'P',✓��P.•, ! ON MY INQUIRY OF THOSE INDIVIDUAL* IMMEDIATELY RES►ONf1ELE roR 4•
<br /> Y T IM+ DETAINING THE INFORMATION. 1 ■ELIEVE THE SUEMITTED INFORMATION 1
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIQ- �{ �� -Y^Ia t,iJL(-�/a/1
<br /> NIFICANT ►ENA4TIES FOR —OMITTING FALSE INFORMATION. INCLUDING' L.lVV/��� •• T\.J' •"�L.•• HAREA
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<br /> p .,��j�n�N�'' rHE EuITY of FINE AND IMPRISONMENT. SEE 1• u.f.e. { Iool wNoSIGNATURE OF PRINCIPAL EXECUTIVE3` ' r»U•!•c• 5 1SIS. (Penalties under these statutes may include fines up to$10,000TYPED OR PRINTED' and)or maximum imprisonment of between 6 months and 5 years) OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br /> COMMENT A140 EXPLA`4ATfION•�OFANY,VIOLATIONS (Reference all attachments here)
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<br /> EPA Form'3320-1•(Rk'i0-79)' 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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