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<br />N AME/TITI ".: PR INC IPAL EXECUTIVE OFFICER
<br />I CERTFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
<br />AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br />ON MY INQUIRY OF THOSE INDIVIDiMl S IMMEDIATELY RESPONSIBLE FOR
<br />DETAINING THE INFORMATION 1 EiELIFVE THE SURMITTED INFORMATION
<br />IS TRUE ACCURATE AND COMPLETE t AM AWARE THAT TI4ERE ARE SIG,
<br />NW ICA NT PENALTIES FOR SUBMITTING FALSE PiFoRMATION INCLUDING
<br />T HE POSSIRILIT V OE FINE AND IMPRISONMENT SEE fe US c § 1001 AND
<br />13 II ,SC A i 316 fp„,te, „,,,,, a ,,,,,„ ,,,,,, ,,,,,d f,,,,,, ki , , 310 (0)
<br />nnd n mann." MiprIstottnear n lnl.cen 0 monlks and S sen1, 1
<br />TELEPHONE
<br />DATE
<br />(
<br />,
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />OFFICER OR AUTHORIZED AGENT
<br />— — -
<br />F ypt CI OR PRINTED
<br />A Era
<br />NUMBER
<br />YEAR
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<br />OAT
<br />rem, .11 n'note
<br />NAME
<br />ADDRESS
<br />COMM
<br />on 11 dt#erent
<br />EACILITI
<br />LOCATION
<br />NATIONAL POLLUTANT
<br />DISCHARGE
<br />(2 16)
<br />FROM
<br />PERMIT NUMBER
<br />YEAR
<br />RE ELIMINATION SYSTEM tNPD
<br />TORING REPORT (DMR)
<br />(17-1R)
<br />MONITORING PERIOO
<br />1 0Ay
<br />f YEAR 1 MCI
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<br />36 re-
<br />DISCHAIRRE NUMBER
<br />DAY
<br />NOTE: Read instructions before comp sting this form.
<br />v; S
<br />Fora roved
<br />OMB Ain. 2000-0015
<br />
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