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PERMITTEE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) po mApplovefl
<br /> Faci/Ip Nansellacarlon I/dlDrrenl)i- ;DISCHARGE MONITORING REPORT(DAIR) 1 OMB No.2D40- I/
<br /> �1 ru»n/`5�T /7//)/ �/. 1 1-16 17-19 NAMF—•.:y_Lz_ }Ja�t/��� �—_-- ) t — YI :r{'L ; Approvalcvhr 12-31-V
<br /> ADDRESB_..,L.�L..:aL�_'f-- � I' ) ' = I N J�I.a:'IE
<br /> PERMIT NUMBER _ DISCHARGE NUAeEp 5
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<br /> FACILITY /L/'�(� I YEAR MO DAY YEAR MO ` DAY _ _ 3 -
<br /> LOCATIOI I I +YX-" r-F•�/ FROM TO
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<br /> (10- ) (11-13) (1+-73) ( 6 ,) f18.79) (30-3I) NOTE: Read Inslruetlons baton Lwmpletlnp this loan.
<br /> I (3 Card Only) QUANTITY OR LOADING (+ Card Only) QUALITY OR CONCENTRATION
<br /> PARAMETER (+6-33) (3 fit) (38-IS); -(+6-33) (3+-61) = r 1 NO. FREQUENCY SAMPLE
<br /> I>< 1 J - EX ANALV60 *TYPE
<br /> (31;7) AVERAGE MA UNITS MINIMUM AVERAGE•.. MAXIMUM UNITS 61fi31 (6+fi8) (69-70)
<br /> "I 1 BAMPLE A:}: 4 f4 SI;PR
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFr uNOfR PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED "ATUIr
<br /> - - TELEPHONE DAT E
<br /> _ NDMFAMILIAPWITHE INFORMATION SUBMITTED HEREIN. AND BASEDON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOIIF'.J, ( iJr/� OBTAINING THE INFORMATION. I BELIEVE tHE SUBMITTED INFORMATIONcYY„ ll.. IS TRUE ACCURATE AND COMPLETE 1 AM AWARE THAT THERE ARE SIG INIFICANT PENALTIES FOR 5UMITTING FALSE INFORMATION INCLUDING •THE POSSRIKITY OF FINE AND IMPRSOnMENT SEE 1B USC E10p1 AND
<br /> 3USC 11319 rPrwff.. older rFry /lamin n nrlWe /mr. uP m EI4Mp ' ` IPAL' ECUTIVE +
<br /> TYPED OR PRINTED a.d n.ma+Imam lman..,nnmm.,/A.ruwn 6lmnnrh.end:+rar.I OFFICER DR�AUTNORRED AGENT-�+ 7OnzNUMBER YEAR NO 'GAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all alruchmenl.T here) ,V.. eaIJ
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<br /> EPA Form 3320-I (Rev. I0-79)PREVIOUS EDITION TO BE USED (REPLACES VA FORM T40 WHICH MAY NOT SE USED.) PAGE E OF
<br /> UNTIL SUPPLY 38 EXHAUSTED I 1/lr A Q i9/UY UjO 1-4.2 U 1
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