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PERMITTEE NAME/ADDRESS Qnclude Faciliry NamdLocatian i/DifferenQ
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<br />FACILITY
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<br />NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPOES)
<br />DISC(H1A6 GE MONITORING REPORT (O(MR;e1
<br />°7TJ 7: ,T n.17 i
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM '' " TO ' ' ~` ' ,I
<br />('14211 (1113) (14151 (M-111 (18-19) (30.Tf1
<br />Farm Approved.
<br />„ , T ,~ ., OMB No. 2040-0004
<br />Approval elrpires 05-31-98
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<br />NOTE: Read InsVUCtions bet ' completing this form.
<br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER 46-53) (5461) (38-45) 46-53 (54-G7) ~( OF TYPE
<br />(~~~ AVERAGE MAXIMUM UNRS MINIMUM AVERAGE MAXIMUM UNITS
<br />(ez831 arv'YS/s
<br />64-68
<br />6&70
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<br /> MEASUREMENT
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<br />V I S U& L MEASUREMENT
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<br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAfl WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY TELEPHONE DATE
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<br /> INQUIRY OF THOSE INDMDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING /
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<br />P,)chard Mulls THE INFORMATION, I BELIEVE THE SUBMnTED INFORMATON IS TRUE,
<br />ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIGNIACANr
<br />PENALTIES FOR SUBMRIING FALSE INFORMATION
<br />INCLUDING THE
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<br />FnvfronmentFtl 1•:)7r1f'~ar ,
<br />POSSIBILRYOFFINEANDIMPRISONMEM.SEEIBU.S.C.51001AND33U.S.C.
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell a(techmenls here)
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<br />EPA Form 3320-1 (OB-95)" Previous editlons may not be used. ~ (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) ,1 ,~ ~ i ^ ~ n . ^ U 7 ~_, f 7 1 PAGE OF
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