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PERMITTEE NAME S (Include NATIONAL POLLUTANT DIS �E ELIMINATION SYSTEM (NPD/.S) Form App, <br /> Fa_dt(1 Nan•-ILacauan rent) DISCHARGE MONI ORING REPORT (I)MR) OMB No.2040-0004 <br /> NAME-- (17-19) Approval expires 9-30-85 <br /> -------------------- <br /> ADDRESS ______________ <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ———————————————————————— MONITORING PERIOD <br /> FACILITY---------------------- YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM TO <br /> ------------------------- <br /> (20-21) (22-23) (24-25) (2627) (2h-29) (30-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION�< <br /> PARAMETER (46-53) (54-61) (38-45 46-53) (54-61 NO. FREQUENCY SSAMPLE <br /> (32-37) ) ( ) EX ANAOLY51 TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 61-63) NALY ) (69-70) <br /> SAMPLE <br /> >. <br /> MEASUREMENT t(�� <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE j <br /> MEASUREMENT <br /> PERMtT <br /> REQUIREMENT * �; <br /> [:1 i'3Ct 0f; <br /> � h� SAMPLE <br /> j f`f,VN MEASUREMENT <br /> 1045 1 0 REQ PERMIT 01 J <br /> UIREMENT * * � 0 i/30 GR <br /> SETT. SOL MEASUREMENT <br /> U <br /> PERMIT <br /> 545 1 0 REQUIREMENT, <br /> 01/30 GR <br /> T DS SAMPLE <br /> MEASUREMENT <br /> 702� PERMIT <br /> (15 1 0 REQUIREMENT 01/90 GR i <br /> �. �:' <br /> SAMPLE >r <br /> MEASUREMENT <br /> /� <br /> PERMIT <br /> 400 1 0 REQUIREMENT r 5.5 * 9.0 01 /07 GR <br /> SAMPLE <br /> G & G MEASUREMENT Y. i <br /> PERMIT <br /> 556 1 0 REQUIREMENT * * * C(ATFiOfv 10 01%07 GF, <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED / <br /> ON MY INQUIRY OF THOSE INDIVIDUAL IMMEDIATELY RESPONSIBLE FOR T\�' <br /> tarries S. Lunan OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION j <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG J <br /> [,F na ae r - Perm 1+s NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING_ <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 4 1001 AND nn -7 H CC r� 27 <br /> 33USC 41319 tP—Inc, under the.e stalut- a Inrlud, hne, up lr, Slow', SIGNATURE OF PRINCIPAL EXECUTIVE ' " //�•—SLJ.� C// 07 L/ <br /> TYPED OR PRINTED and ,r manmum lmpre—nmrou,d h,,Iuwen h month,and i%ear%t OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all atimlitlents here) <br /> 'A Form 3320.1 Rev. f 0-79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> IINT11 CIIPPI V IC CYunI c— <br />