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PERMITTEE NAME/ADDRESS anrladr F4waky .v'ameltpeation if Ut7Jertnq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />PERMIT NUMBER, D s - A.RGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />()MB No 2040-000, <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br /> <br />OF <br />SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penult% w law that this ducunrent and all attachments were <br />d TELEPHONE DATE <br /> prepared under m> direction nr supervision in accordance with a syxtem designe <br /> to assure that qualified prrsonnel prupert? gather and rsaluae the information <br /> submitted- Rased on ms inquire of the peram nr pers.m+ whn manage the ssstem- <br /> or those persom dimctiy respmsiblv, for gathering the inrormation, the inrnnnatinn <br /> suhmitlM is. to the bet or m% knowledge and lecher, true, accurate, and compirk. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there art significant penalties for •ubnuuing (21st information, <br />including the r-ihili1% (rr fine, and imprhrmment for krowing viidatirm+. OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part farm.