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PERMITTEE NAME/ADT•ESSQndad•FxibryNaw*ILo auon(jDw%,wns)
<br />NAME U A 6% if E FF k. E :, •i' r
<br />ADDRESS CA is ;i J r4 J U K C I' I DN
<br />27}i LAWYER DRIVE
<br />DU#:ANC,D C3 b1351
<br />FACILITY O A K 't I D r; 1. r' tl F "r; : 1 L t;
<br />LOCATION
<br />r, TT 1,• .tlbJ;;.1. UR'{T't'Y PR+--:TnF-.,-
<br />NATIONAL POLLUTANT r -CHARGE ELIMINATION SYSTEM (NPDES)
<br />Form Ap
<br />ved.
<br />DISCHARG NITORING REPORT (DMR)
<br />12-161 17-191
<br />FREQUENCY
<br />ANALYSIS
<br />ANA -
<br />(6¢68)68)
<br />-,-OMPN,
<br />?•-0004,
<br />MAXIMUM
<br />UNITS
<br />MINIMUM
<br />?i `• !� I r'r '
<br />-1 ' Approve
<br />„
<br />ires 05=31-98
<br />!;
<br />PERMIT NUMBER
<br />DISCHARGE
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<br />t_ s. ,•c
<br />MONITORING PERIOD
<br />!
<br />is h U 0 1 D 0
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<br />YEAR I MO
<br />DAY
<br />PERMIT
<br />REQUIREMENT
<br />YEAR I MO
<br />I DAY
<br />r
<br />t, '• t;f
<br />y r
<br />t
<br />FROM
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<br />(20-21) 122-23) (24-25) (26-27) (28-29) 130-311
<br />NOTE:.Read instructions before
<br />Completing
<br />this form.
<br />PARAMETER
<br />132-37/
<br />(3 Card Only) QUANTITY OR LOADING
<br />(46-53) (54-611
<br />(4 Card Only) QUANTITY OR CONCENTRATION
<br />(36-45) (46-53 (54-61/
<br />NO.
<br />EX
<br />162 -631
<br />FREQUENCY
<br />ANALYSIS
<br />ANA -
<br />(6¢68)68)
<br />SAMPLE
<br />TYPE
<br />169-701
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
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<br />SAMPLE
<br />MEASUREMENT
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<br />MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON
<br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. ! 1001 AND 33!`1'
<br />U.S.C. f 1318. (ForiaN�ee under Meas afth0ox may lneh de rawa up to i 101000
<br />andormulmunlmpdowinraneofbetween 6months end 6 yomml
<br />i
<br />TELEPHONE
<br />DATE
<br />/ } /
<br />f / !L
<br />'!'r•
<br />SIGNATURE OF PRIN IPAL EXECUTIVE
<br />OFFICER OR AUTHORIZED AGENT
<br />TYPED OR PRINTED
<br />AREA
<br />CODE NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />VVMMCIY 1.7 AIYV cArLAIYA I IVIV VY AIYT VIVLA I IVIYD IfI&T8r6nC8 Ott 8FF8CnrnanF5 nerel
<br />-.i.TTLEAt,L:. LDS 5U I , .t
<br />L ' I'�II' Aiti�LLi:S ONLY IF C= IU -YF-,, 24 -;in PRe,:iz :.Yi.,t't i". CL�Tit
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<br />4u;:U, TSS E rRSIt+ LIMITS :TILL NOT OF TD Itc Irr?T� ` F:Asu,.r::'',L:�C�-- �' T. r'.I A P(7
<br />EPA Form't3320-1`108 95 P vious'editionS"may be used.' '" " e (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
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