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PERMITTEE NAME/ADDRESS (Jnclyde, r �J NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDF.S) �FO(m Approad
<br /> Facility Nmne/Locarlon III dlBere ) �J(/
<br /> O/�1Prse�%I//fi/ram f DISCHARGE MONITORING REPORT(DAfR) OMB No.2D40MW
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<br /> FACILZ—y—�LL __ �¢�.�� Q Uru��! YEAR MO DAY YEAR MO- DAYL ^ , _ _ N 3
<br /> LOCATION I LI L— ,/I Ff�OM TO - L r 1 i. .t C '•'
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<br /> Al1 (20.21) (33-23) ( 6n) ( 6'. ) (78.79) (3oa1) NOTE: Read Inetruetlona baloro eompletinp this form.
<br /> ' (3 Card Only) QUANTITYIOR LOADING (I Card Only)a QUALITY OR CONCENTRATION
<br /> PARAMETER (46-73) (5461) (38-43) (46-53) (5461) 2. C NO.j FRECOUFNCY SAMPLE EX ANALYSIS
<br /> TYPE
<br /> (37-37) AVERAGE MAXIMUM UNITS MINIMUM -AVERAOE• MAXIMUM .r I_ UNITS - 6)63) (616d) (69.70)
<br /> 1 SAMPLE is L.+}ia C•i! Q5,-0+F7W
<br /> MEASUREMENT
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<br /> MEASUREM NT
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<br /> MEASUREMENT
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<br /> BAMPLEIp °AS-4}91, G'i'eJP•F A' ml(Li l�llP4 ��Y 1tl:
<br /> MEASUREMENT
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT 91 HAVE PERSONALLY EXAMINED _� ". _"] Y ;>rs y :- -TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN. AND BASED •< _ \ C J[ I ]E
<br /> I /r(��) ,r ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> f�/•c r itc to r /` '! OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION
<br /> I IS TRUE. ACCURATE AND COMPLETE 11 AM "ARE THAT THfRE ARE SIG
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDINGI "• i )
<br /> THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE ,B USC I ,COI AND 91GNATURE OF PRINCIPAL EXECUTIV!• ' - .[/1f
<br /> 33USC 11319 fPrealerx under thew INmr.m mar mrludr fines uy rn Slgnlr
<br /> TYPED OR PRINTED Send n.maximum imamnnm.mn/Aeruwn6mr,nthaand.5.ean.l a ' - _OFFICER OR-AUTHORIZED AGENTiM1AHEA
<br /> •NUMBER YlAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY-VIOLATIONS (Reloence.11 ww,hrient,here) r n_ = _ _ ', ; I n ^• N -
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<br /> EPA Form 3320.1 (RSV. 10.79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM 1.40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTIL SUPPLY 18 EXHAUSTED U 1/�a El_l/L)Y U,o I tea.34 U A.
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