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PERMITTEE NAMEIADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION sYSTEM(Mpwm <br /> Facility Nama&ocaWn if different) DISCHARGE MONITORING REPORT (DMR) <br /> NAME CDR (&re) (r7-19) Form Approved. <br /> ADO Q 6 Minor OMS No.2040-0004 <br /> p M8 R I DISCHARGENUMBER I Approval expires 10-31-94 <br /> F-Final <br /> FACILITY A(,W(As E MONITORING PERIOD <br /> LOCATION Uh{'WCQRP6R/kTED 6—:PA57 COU= YEAR MO DAY I I YEAR I MO DAY NO DISCHARGE +_ <br /> ATTENTION FROM TO p <br /> (20 21) -23) (24 2) (2ti 27 (28 28) 30-31) NOTE: RNd fratrucUon>t bsMro complotlnp this forte.30-31) <br /> FREOU <br /> PARAMETER (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION NO. OF SAMPLE <br /> (32-37) (46-53) (54-81) (38-4.9 (46-53) (54-61) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 16243 t (64-68) (58-70) <br /> SAMPLE ****** ****** ***t** ****** t***** <br /> MEASUREMENT #* *** **t##* #***** <br /> SAMPLE <br /> MEASUREMENT ***### #ttt## *#**** <br /> LUAU- <br /> PERMIT <br /> REQIIiREMENf <br /> SAMPLE #t##*# #****# ##*##* ###ttt ****** <br /> MEASUREMENT ###*## ###tt# ###tt# <br /> #"'�" id 'i'fl'1� •c • yR h _:.. ##t### .��-' ��•�'.'.• N ':*#�Tt� <br /> mw <br /> SAMPLE ###### *####* t###tt *##### *#**** <br /> MEASUREMENT <br /> SAMPLE #*##t# *##*## ##**t* #***#* ****** <br /> MEASUREMENT ###### #t#### #*##*# <br /> Wq <br /> REQIAREMENT *tt r lay. L ###### 3.. +;x, <er a• <br /> SAMPLE <br /> MEASUREMENT ****# ###### #*#**# <br /> PERMIT <br /> SAMPLE ##t#** #*t##* **##** ##t### t###** <br /> MEASUREMENT ###*** ####*# tt*#** <br /> REQt3'lRfi1` ENl' r <br /> NAMLMITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE DATE <br /> n - r AM FAMILIAR WITH THE IN MI FORMATION SUBMITTED HEREIN;AND BASED ON MY <br /> l3/ t'J INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br /> THE INFORMATION,1 BELIEVE THE SUBMITTED INFORMATION IS TRUE,ACCU <br /> ®"kTOp RATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PE <br /> 1� NALTIES <br /> FOR SUBMITTING FALSE INFORMATION,INCLUDING THE POSSIBILJTY OF FINE 9A b1a <br /> AND IMPRISONMENT. SEE 1S U.S.C.11001 AND 33 U.S.C.51319. Z l2 6 <br /> TYPED OR PRINTED (Asnatries under d w awtut"amy hnohrds Mrs up to i10,000 and or msbmum SIGNATURE OF PR) ALE UT1VE AREA <br /> Impilamm nt of between a months end 5 yaw.) OFFICER OR AUTHORIZED AGENT CODE NUMSER YEAR MO DAY <br /> �Nl.Y AT ±#15 Sm Re, - gEEe I -Dpd y1 fine PtA M(iifidi&o sao6tAI. ofn (��'N1jI��kL �>;� Dccu2R�p 29801G <br /> EPA FORM 3329-1(REV.946)tbsvtous edttlons my b9 wad. V�s L 1 r7 �© �' s ' I G� 000051950315-1633 PAGE 2 OF 2 <br /> [REPLACES EPA FORM T40 WHICH MAY T BE USED) <br />