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PERMITTEE ADDRESS (Include NATIONAL POLLUTAN HARGE ELIMINATION SYSTEM (A'PDES) pproved. <br /> fuclh.1 A,,.le n if dioerent) DISCHARGI NITORING REPORT (DhfR) No.2040-0004 <br /> NAME 9 r 1 U (2-16) (17-19) Approve/expires 9-30-85 <br /> --------------------- <br /> ADDRESS— _ ---------------_ <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ------------------------ <br /> -——————————————————————— MONITORING PERIOD <br /> FACILITY--------------------- YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM - TO <br /> (20-21) (22-23) (24-25) (26 2 ) (2R-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 FREQUENCY <br /> (46-53) (54fi1) NO. OF SAMPLE <br /> (32-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63) (64-68) (69-70) <br /> r <br /> t L SAMPLE ' <br /> MEASUREMENT <br /> t�.IUI f l PERMIT �:.ts.c 3i '1, j' 7 <br /> REQUIREMENT <br /> r `r <br /> SAMPLE <br /> `j MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> C7 - MEASUREMENT - <br /> —' PERMIT <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 /> 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 /> r - _ ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR - <br /> ...u�l`.�-� OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION ti7�-'�' W L / �✓ <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> t' NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 4 I001 AND i . i�• r! <br /> 33USC §1319 tPrn.1w, undrr thew statutr. ma. Inrlude fi—, up to SIO)MY, SIGNATURE OF PRINCIPAL EXECUTIVE 6.�� ��.: <br /> TYPED OR PRINTED and ur masmmm Imprinnrl mrnt ul hel.—6 month,and i OFFICER OR AUTHORIZED AGENT AREA <br /> El NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all uttuchments here) <br /> EPA Form 3320-1 (Rev. 10-79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY IS EXHAUSTED <br />