TENNESSEE VALLEY AUTHORITY -DISCHARGE ...-pl PPlnrl- EFFLUENT From 1 02 05 1 01 To 02105 31 Form Approved. OMB No. 2040-0004 NO DISCHARGE L__J * NOTE: Read instructions before completinq

Tennessee Valley Authority, Post Office Box 2000, Soddy-Daisy, Tennessee 37379-2000

June 12, 2002

State of Tennessee Department of Environment and Conservation Division of Water Pollution Control 401 Church Street, 6th Floor Annex Nashville, Tennessee 37243-1534

Attention: Ms. Evelyn Haskin, Enforcement & Compliance

Dear Ms. Haskin:

TENNESSEE VALLEY AUTHORITY - DISCHARGE MONITORING REPORT FOR SEQUOYAH NUCLEAR PLANT

Please find enclosed the Discharge Monitoring Report (DMR) of May 2002 for Sequoyah. Please contact me at (423) 843-6700 if you have any questions or comments.

Si erely,

Diedre B. Nida Environmental Supervisor Signatory Authority for Richard T. Purcell Vice President Sequoyah Nuclear Plant

Enclosure cc (Enclosure):

Chattanooga Environmental Assistance Center Division of Water Pollution Control State Office Building, Suite 550 540 McCallie Avenue Chattanooga, Tennessee 37402-2013

Y/U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555

Printed ow recyled paper

PERMITTEE NAME/ADDRESS (Include Facilitv Name/Location if Different)

Name TVA - SEQUOYAH NUCLEAR PLANT

Address BOX 2000 ____(INTEROFFICE SB-2A)

SODDY - DAISY TN 37384 Facilitv TVA - SEQUOYAH NUCLEAR PLANT Location HAMILTQN CUONTY

ATTN: Diedre B. Nida

NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) MAJOR DISCHARGE MONITORING REPORT (DMR)

(SUBR 01)

PERMIT NUMBER H DISCHRGE NUMBER DIFFUSER DISCHARGE

M--NITnIINI(-pl PPlnrl- EFFLUENT

From 1 02 05 1 01 To 02105 31

Form Approved.

OMB No. 2040-0004

NO DISCHARGE L__J *

NOTE: Read instructions before completinq this form.

PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE EX OF TYPE

AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS

TEMPERATURE, WATER DEG. SAMPLE 24.7 (04) 0 31 / 31 MODELD CENTIGRADE MEASUREMENT

00010 Z 0 0 liPERMITV 30.5*~* DEG. C. SE K E

INSTREAM MONITORING , R ECUI L #,". IVIA

TEMPERATURE, WATER DEG. SAMPLE ******** ******** ******** 35.9 0 31/31 RCORDR CENTIGRADE MEASUREMENT

00010 1 0 0 P F. ..... * T.3 ........ EPORT DEG. C. S0EE GREQ EFFLUENT GROSS VALUE D-IL :th 4 MXii .IT PH SAMPLE .......******* *73*72 0 10/31 GRAB

MEASUREMENT

00400 1 ~0 0 I ********* 6~C.0 9.0 j SU WVEEKL, 'GRAD EFFLUENT GROSS VALUE EIRE,.l- EW .> •.'. ; A-NII' " I

SOLIDS, TOTAL SUSPENDED SAMPLE ******** ******** 6***(19) 0 5 / 31 GRAB MEASUREMENT 6* (19)

00530 1 0 0 1 ERMl1IT 30Th 100~** ~ ~ '** ~ 'j<~ MG/L V WýKLY~ GR~AB

EFFLUENT GROSS VALUE REQ.IRE T N4 M AVG DAILYM•MX OIL AND GREASE SAMPLE ........ ........ **** <5 <5 (19) 0 5 / 31 GRAB

MEASUREMENT

00556 1 0 0 1P PRMIT • •0 , ' MG/L I.. E KLY•'.AB*

EFFLUENT GROSS VALUE ,.j: ,, FLOW, IN CONDUIT OR THRU SAMPLE 1741 (03) *****_., 0 31,/-31 RCTRDA TREATMENT PLANT MEASUREMENT 0

50050 1 0 0 ~ ERU~M MIT 4~m' REPORT MGD C **~* ~ **~O&1Tff4 cOD

EFFLUENT GROSS VALUE DAL MX u ouUs CHLORINE, TOTAL RESIDUAL SAMPLE **** <0.009 0.021 (1) 0 43 /31 GRAB MASUREMEN

50060 1 0 0 ~ PERMIT<¾ k*~ '~ k M/ WEEK- OALGTDi EFFLUENT GROSS VALUE D.~ ~ ~ AYS

NAME/TTLE PRINCIPAL EXECUTIVE OFFICER I Cerfify under penalty of law that this document and all attachmenta ware prepared undemy ( f i, ')- TELEPHONE DATE uirection or supervision in accordance with a system designed to assure that qualified personnel

Richard T. Purcell properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the Environmental Supervisor

Site Vice President nformation, the information submitted is, to the best of my knowledge and belief, true, accurate, __ISupervisor _ 423 843-6700 02 06_13 and complete. I am aware that there are significant penalties for submitting false Information, SIGNATURE OF PRINCIPAL EXECUTIVE including the possibility of tine and imprisonment for knowing violations. I

TYPED OR PRINTED OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO CODE

COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)

No closed mode operation. The following injections occured: 1. PCL-222 (max. calc. conc. was 0.062 mg/L--limit 0.100mg/L) 2. CL-363 (max. calc. conc. was 0.015 mg/L--limit 0.100mg/L) 3. PCL222/PCL-401 (max. calc. conc. was 0.021mg/L--limit 0.100mg/L)

EPA Form 3320-1 (REV 3199) .Previous editions may be used Page 1 of 2

PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)

Name TVA - SEQUOYAH NUCLEAR PLANT Address BOX 2000

(INTEROFFICE SB-2A)

SODDY - DAISY TN 37384 Faciitv TVA - SEQUOYAH NUCLEAR PLANT Location HAMIL__TON O _NTY


NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)

DISCHARGE MONITORING REPORT (OMR)

TNO06450 101 m ERMIT NUMBER TDSCHARGE NUoBER

I MC)NITOINC- PFPIOD t IYEAR I MO DAY. I YEA612 MC)I DAY FromI 02 105 01 1 Tol1 02 105 1311

MAJOR Form Approved.

(SUBR 01) OMB No. 2040-0004

F - FINAL

DIFFUSER DISCHARGE

EFFLUENT

*** NO DISCHARGE

NOTE: Read instructions before completing this form.

PARAMETER

TEMPERATURE - C, RATE OF CHANGE

B2234 1 0 0

EFFLUENT GROSS VALUETEMP. DIFF. BETWEEN SAMP. &

UPSTRM DEG.C

D0016 1 S 0

EFFLUENT GROSS VALUE

MEASUREMENT i

DEG C /HR

(04)

DEG. C.

I I

MEASUREMENT

'AMl'L I MEASUREMENT

MEASUREMENT

BORON, TOTAL

01022 1 0 0


I I I

III I I

I I

<.Z I <U.ZMEASUREMENT

<0.2 (19) 0 1/31 GRAB

MG/L

SAMPLE MEASUREMENT

.,� 7.'. � C'.

NAME/TITLE PRINCIPAL EXECUTIVE OFFICER Certify under penalty of law that this document and all attachments wera prepared under my TELEPHONE DATE R a cdirection or supervision in accordance with a system designed to assure that qualified personnel

Richard T. Purcell properly gather and evaluate the Information submitted. Based on my Inquiry of the person or parsons who manage the system, or those persons directly responsible for gathering the Environmental Supervisor

Site Vice President nformatIon, the Information submitted is, to the best of my knowledge and belief, true, accurate, 423 843-6700 02 06 13 and complete. I am aware that there are significant penalties for submitting false Information, SIGNATURE OF PRINCIPAL EXECUTIVE including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY

TYPED OR PRINTED ICODE


CCW data for May 2002 is attached. Toxicity was sampled May 5-10, 2002, report will be submitted with the quarterly DMR.

EPA Form 3320-1 (REV 3/99) Previous editions maybe used Page 2 of 2

t U j

CCW Data for May 2002

CCW CHANNEL

DATE EXTRACTABLE PETROLEUM HYDROCARBONS COMMENTS (mq/L)

May 13, 2002 < 0.5

CCW TRENCH DISCHARGE

DATE EXTRACTABLE PETROLEUM HYDROCARBONS COMMENTS

(mq/L)

May 13, 2002 < 0.5

Page 1

PERMITTEE NAME/ADDRESS (include Facility Name/Location if Different)


(INTEROFFICE SB-2A). SODDY - DAISY TN 37384

Facility TVA - SEQUQYAHNUCL__ARPLANT . . .Location HAMILTON COUNTY


NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) MAJOR Form Approved. DISCHARGE MONITORING REPORT (DMR) (SUBR 01) OMB No. 2040-0004

026450 103 F - FINAL

L ERMIT NUMBER DISCHARGE N LOW VOL. WASTE TREATMENT POND

P.A C-NI IITC'• r1IN.I (' nr'nIc-r• EFFLUENTFrom 021 D0501 To 02 I3 Y i f NO DISCHARGE =I.


PARAMETER

PH

00400 1 0 0


SOLIDS, TOTAL SUSPENDED

00530 1 0 0


OIL AND GREASE

00556 1 -0 0


MEASUREMENT

PER~MIT 19 250 REURMN W V 17. ifc& $ aV MX)+

(26)

LBS/DY

FLOW, IN CONDUIT OR THRU SAMPLE 1.247 1.526 (03) TREATMENT PLANT MEASUREMENT

50050 1 0 0 PESRMIT RE R REP.ORT. MGD EFFLUENT GROSS VALUE REQ VUI_________

SAMPLE MEASUREMENT

MEASUREMENT I I

MEASUREMENT

I NAME/TITLE PRINCIPAL EXECUTIVE OFFICER

Richard T. Purcell

Site Vice President

TYPED OR PRINTEDJ ncluoin

under penalty of law that this document and all attachments were prepared under my n or supervision In accordance with a system designed to assure that qualified personnel y gather and evaluate the information submitled. Based on my inquiry of the person or who manage the system, or those persons directly responsible for gathering the

tion. the information submitted is, to the best of my knowledge and belief, true, accurate, "nplete. I am aware that there are significant penalties for submitting false information. g the possibility of fine and imprisonment for knowing violations.


Environmental Supervisor

SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT

EPA Fr,,n, n 55iA opt1 -onO 011-~,,,. 1.U;-,. ,,. .

Page 1 of 1

SAMPLE MEASUREMENT (26)

LBS/DY

LTOTALN

- . % I use , nsmaybeused

I I

I ~ ~ ~ ~ I ld .. J' l t I'IJ'N=V r-F1-1"1•]

incluoln

I

I I


Nome TVA - SEQUOYAH NUCLEAR PLANT

Address BOX 2000 (INTEROFFICE SB-2A)

. . . SQDDY - DAISY TN 37384 Focilitv TVA - SEQUOYAH NUCLEAR PLANT Location HAMILTON COUNTY

AFrN: Diedre B. Nida

NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) MAJOR

DISCHARGE MONITORING REPORT (DMR) (SUBR 01)

TN0026450 1 107 G F - FINAL

PERMIT NUMBER DISCHARGE NUMBER METAL CLEANING WASTE POND

SMONITORPING' PI::RIOID EFFLUENT

YEA YFAR I MO I ... NO DISCHARGEMXX From 0 9 05 1 To 02 N 05 R I beforeOARG

NOTE: Read instructions before corr

Form Approved.

OMB No. 2040-0004

npleting this form.

PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE EX OF TYPE

AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS

PH SAMPLE (12) MEASUREMENT

PK T- 6.0~' SU 0IY GA

00400 1 0 0 RT *~.6 DIY~OA EFFLUENT GROSS VALUE t ----- --- I.MINI'IM'um-1 MAXIMUM PHOSPHORUS, TOTAL (AS P) SAMPLE ****** ******** *

MEASUREMENT

00665 1 0 0 PER~~MIT~ 11;0;* -~ 444* MG/L DAIL'( CAi 0 f4 1 FOSIO

EFFLUENT GROSS VALUE .. DAILY tMX

SOLIDS, TOTAL SUSPENDED SAMPLE ******** ******** * ******** (19) MEASUREMENT

00530 1 .0 0 PERMIT ,. MIG/L DAILY.IPS

EFFLUENT GROSS VALUE 7IYII OIL AND GREASE SAMPLE **** ********

MEASUREMENT (19)

00556 1 0 0 15/~ *44 ~ ~ *~4 MIGIL <DAILY GRAB ERE,.UIRE vEHT EFFLUENT GROSS VALUE DAILY DAI X COPPER, TOTAL (AS CU) SAMPLE ******** ****** ******** ********

MEASUREMENT (19)

01042 1 0 0 'M 1 *4 4" 4* 0 .... ..... MG/L .. DAILY COMPO: EFFLU E N T G R O S S V A LU E. R E ,,A . k. ....

IRON, TOTAL (AS FE) SAMPLE (*** t MEASUREMENT **(19)

01045 1 0 0 PERi T, N' <. 1,'.0 "/ .. ..

EFFLUENT GROSS VALUE R,, r DAILY .. K1iV :•MLY;. •

FLOW, IN CONDUIT OR THRU SAMPLE (03)**** TREATMENT PLANT MEASUREMENT (03)

50050 1 0 0 1~ EPEMI R ODA ILY/ CALCTD) EFFLUENT GROSS VALUE mOIRIb AV DAILY7 IVIRX. MD ~**** ~ **4* ~444*

NAME/TITLE PRINCIPAL EXECUTIVE OFFICER It Certify under penalty of law that this document and all attachments were prepared under my # .4')TELEPHONE DATE ________________________________________- direction or supervision in accordance with a system designed to assure that qualitied personnel

Richard T. Purcell property gather and evaluate the intormation submitted. Based on my inquiry ot the person or persons who manage the system, or those persona directly responsible tor gathering the cur Environmental Supervisor42 83-70 2 06 1

Site ~ ~ ~ ~ n ViePeietItrmation, the intormation submnitted is ,to the best of my knowledge and bellet, true, accuate, 423____843-6700_______02__06___13_ Site Vce Preidentand complete. t am aware that there are signiticant penalties tor submitting false intormation, SIGNATURE OF PRINCIPAL EXECUTIVEI TYE RPITDincluding the possibility ot tine and Imprisonment tor knowing violations. OFFICER OR AUTHORIZED AGENT AREA INUMBER YEAR MO DAY


No phosphate bearing chemicals were employed. No Discharge this Period

EPA Form3320-I REV 3/99 Previos editins maybeused Pae 1 of

EPA Form 3320-1 (REV 3/99) Previous editions may be used Page I of 1



(INTEROFFICE SB-2A) SODDY - DAISY TN 37M384 ._____

Facility TVA - SEQUOYAH NUCLEAR PLANT Location HAMjILjON COUNTY


PARAMETER

NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) MAJOR

DISCHARGE MONITORING REPORT (oMR) (SUBR 01)

TN0026450 1 110 G F - FINAL

PERMIT NUMBER I DISCHARGE NUMBER RECYCLED COOLING WATER

MnNITC)PINGC PFRIC)rD

Form Approved.

OMB No. 2040-0004

] EFFLUENT

Fro m n 015 01 To I 0- I DA ... NO DISCHARGE FXX ... NOTE: Read instructions before completing this form.

QUALITY OR CONCENTR

UNITS I MINIMUM I AVERAGE

ATION NO. FREQUENCY SAMPLE EX OF TYPE

MAXIMUM UNITS ANALYSIS

PH

00400 1 0 0



00530 1 0 0


OIL AND GREASE

00556 1 10 0


COPPER, TOTAL (AS CU)

01042 1 0 0


IRON, TOTAL (AS FE)

01045 1 0 0


PHOSPHORUS, TOTAL (AS P)

00665 1 0 0


FLOW, IN CONDUIT OR THRU TREATMENT PLANT

50050 1 0 0


MEASUREMENT

PERMIT j.~~r,* ~~i** R[ ;)1RE I I'

SAMPLE MEASUREMENT

direction or supervision in accordance with a system designed to assure that qualified personnel

Richard T. Purcell properly gather and evaluate the information submitted. Based on my Inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the Environmental Supervisor 423 843-6700 02 06 13

Site Vice President Information, the Information submitted is , to the best of my knowledge and belief, true, accurate, 4 843-6700 02 06 13 Sand complete. I am aware that there are significant penalties for submitting false information, SIGNATURE OF PRINCIPAL EXECUTIVE I including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY

TYPED OR PRINTED I I A Z ERAR


No Discharge this Period

MEASUREMENT

MEASUREMENT

-I

(12)

SU

1 (19)

MEAMSR'LM MEASUREMENT

Z ,IV I r'L t: MEASUREMENT

Page 1 of 1

I

(19)

EPA Form 3320-1 (REV 3/99) Previous editions may be used



(INTEROFFICE SB-2A)

SODDY - DAISY TN 37384 Facilitv TVA - SEQUOYAH NUCLEAR PLANT Location HAMILTON COUNlY



DISCHARGE MONITORING REPORT (DMR)

TNO265 0 N MB6 PERMIT NUMBER I DISCHARGE NUMBER

J MnNITOJIC)Rf[- PFRIQQ SYFAI[R M) I6 DA I YEVAR 1. Mo I AY

FromJ 021051011 To 702 7 05 31

MAJOR Form Approved.

(SUBR 01) OMB No. 2040-0004

F - FINAL

BACKWASH

EFFLUENT

SNO DISCHARGE


NAME/TITLE PRINCIPAL EXECUTIVE OFFICER certify under penally ot law Ihat this document and all eltachmenla were prepared under myNAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Certify under penalty of law that this document and all attachments were prepared under rry

direction or supervision in accordance with a system designed to assure that qualified personnel Richard T. Purcell properly gather and evaluate the information submitted. Based on my inquiry of the person or

persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate,

Site Vice President and complete. I am aware that there are significant penalties for submitting false information, including the possibility of line and imprisonment for knowing violations.

TYPED OR PRINTED

COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference oil ottachments here)

Operations is required once per shift to perform visual inspections.

EPA Form 3320-1 (REV 3199) Previous editions may be used Page 1 of 1


Name TVA - SEQUOYAH NUCLEAR PLANT

Address BOX 2000 (INTEROFFICE SB-2A) SODDY - DAISY TN 37384

Facility TVA - SEQUOYAH NUCLEAR PLANT Location HAMILTON COUNTY



DISCHARGE MONITORING REPORT (OMR)

TN0026450 1 117 G PERMIT NUMBER DISCHARGE NUMBER

M~ON]IT)RING' PFRIODI I YEAR1 Mn I DAY t yF,1 YEA 1 0 A

Fo 021051 01 1To 02105 31 1I

Form Approved.

OMB No. 2040-0004MAJOR

(SUBR 01)

F - FINAL

BACKWASH

EFFLUENT

NO DISCHARGE = **


QUALITY OR CONCENTRATION

.1. r 7

AVERAGE

* *** * * * *

MAXIMUM

0

I TREORT~iL

UNITS

(00)

PASS=O FAIL=1

NO. EX

0

FREQUENCY OF

ANALYSIS

1/31

7-EE VISUAL PERM11T

___I _______ . ....______._...__ ,..

NAME/TITLE PRINCIPAL EXECUTIVE OFFICER

Richard T. Purcell

Site Vice President

TYPED OR PRINTED

I Cerfity under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel Droperly gather and evaluate the information submitted. Based on my inquiry of the person or 3ersons who manage the system, or those persons directly responsible for gathering the Environmental Supervtsor nformation, the information submitted is, to the best of my knowledge and belief, true, accurate, _ and complete. I am aware that there are significant penalties for submitting false information, SIGNATURE OF PRINCIPAL EXECU ncluding the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGEI

COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) Operations is required once per shift to perform visual inspections.

EPA Form 3320-1 (REV 3/99) Previous editions may be used

UNITS MINIMUM

SAMPLE TYPE

VISUAL

Page I of I

-i

I I I I I

I I I I I

I I I I I



(INTEROFFICE SB-2A_ SODDY - DAISY TN 37384

Facility JVA - SEQUOYAH NNUCLEAR PLANT Location HAMILTONCOUINTY


NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) MAJOR Form Approved.

DISCHARGE MONITORING REPORT (DMR) ) OMB No. 2040-0004 (S U B R 0 1 )0 M N o 2 4 - 0 4

Z TN0026450 F 118G F- FINAL

PERMIT NUMBER WASTEWATER & STORM WATER

KACM1-tlT-D IlrtC DDIC-tI.- .. ,-

1 EFFLUENT

F Ro IT VFA IIYA M" DAY-] NO DISCHARGE X X .. Frm [NOTE: Read instructions before completing this form.

PARAMETER FREQUENCY SAMPLE OF TYPE

ANALYSIS

OXYGEN, DISSOLVED (DO)

00300 1 0 0


MG/L


00530 1 0 0


SOLIDS, SETTLEABLE

D0545 1 "0 0


FLOW, IN CONDUIT OR THRU TREATMENT PLANT

50050 1 0 0


SAMPLE MEASUREMENT

O / M IL " **

MEASUREMENT

PERMIT 4 -EPORT ' RLPORT

SAMPLE MEASUREMENT

(19)

MG/L

(25)

ML/L

(03)

MGD ONCE/, ESTIMA1, BATVC67H

MEASUREMENT

MEASUREMENT I I I I

NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Certify under penalty of law that this document and all attachments were prepared under my TELEPONE DATE - direction or supervision in accordance with a system designed to assure that qualified personnel 6tlc IU-1LtTEEPON-DT

Richard T. Purcell properly gather and evaluate the Information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the Environmental Supervisor SieVc Peietnformation, the information submitted is, to the best of my knowledge and belief, true, accurate, 423 843-6700 02 06 13 and complete. I am aware that there are significant penalties for submitting false Information, SIGNATURE OF PRINCIPAL EXECUTIVE Sincluding the possibility of uine and imphsonment for kno wting violations , I

PED OR PRINTED t aOFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY


During this reporting period, there has been no flow from the Dredge Pond other than that resulting from rainfall.

i

•t

t

EPA Form 3320-1 (REV 3/99) Previous editions may be used Page I of 1

Documents

TENNESSEE VALLEY AUTHORITY -DISCHARGE ...-pl PPlnrl- EFFLUENT From 1 02 05 1 01 To 02105 31 Form Approved. OMB No. 2040-0004 NO DISCHARGE L__J * NOTE: Read instructions before completinq