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PERMITTEE NAM SS (Include NATIONAL POLLUTANT DI RGE ELIMINATION SYSTEM (NPDES) FO roved <br /> Fucalm Aame/Loca rent) .. - DISCHARGE M ORING REPORT (DMR) 0M .2040-0004 <br /> NAME---- - �- - (2-16) (17-19) <br /> — ------------_—_------ Expires 2-29-84 <br /> ADDRESS - ' -a 000000213 002 <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ----=--_---------------- MONITORING PERIOD <br /> FACILITY ———————————————————— YEAR MO DAY YEAR MO DAY <br /> CT LOAI--ON <br /> -- -------------------- <br /> FROM TO <br /> (20-21) (22-23) (24-2s) (26 ) (18-29) (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) (5"l) NO. Fq EOUENCV OF SAMPLE <br /> (32.37) �< EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63) (64-68) (69-70) <br /> SAMPLE <br /> FLp• C`FF'`I^1 Tj MEASUREMENT NO Discharge <br /> PERMIT G <br /> REQUIREMENT /, �. . <br /> SAMPLE <br /> T-) T_,-7 I G J/;C MEASUREMENT P w t P, + + t y <br /> FL�-'F `F� PERM[T `r., i�/L <br /> REQUIREMENT v, N� Y 'l' '7ti P ';' s 'P 1•' yt' !!` 7 L "�.. I'!i' ir:i <br /> SAMPLE <br /> Ir{01 �TC.-T- MEASUREMENT <br /> R AT LE/D4. tV.G/L <br /> o <br /> •1CF.CiY#Q6M8SLT - its•:+,. .«. "".:'- .,. _ -w'' '"':' Y „.�Ac')atyks�r r' •,1.. >�$„n'agy+'be' ;D.M.s. %p;`s!!".a,:e.o; t. <br /> SAMPLE N <br /> PH,FIELO MEASUREMENT y, r <br /> PERMIT _ S L% <br /> L( n R8QUEREM£NT <br /> r• SAMPLE <br /> I L ?< G'-c:+.*'^.�• MEASUREMENT <br /> L 'PERMIT I u/L <br /> u„ REQUIREMENT �• '}' �i,' (M lM YC ?: ;� :' Y; 71- '' '� to #: { 1++�� VT <br /> _ SAMPLE <br /> MEASUREMENT <br /> PfitMIT <br /> r REQUIREMENT ,r. ,y .,I, # .,t !� 7►• s #' 7i` 7k yf, Y" tt w P Yr rr !s' /C;f. �'+F, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> !RffiI?UIREMENT <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 INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> James S. Lunar IS TRUE THE <br /> AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> NiFICANT PENALTIES FOR SUBMrtTING FALSE INFORMATION INCLUDING <br /> Manager - Permits THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IB USC 11001 AN <br /> 3 U S C !131 Y (Po"luee tinder thew etawet — -elde fain ap to ll tl <br /> SIGNATURE OF PRINCIPAL EXECUTIVE 602 774-5253 87 04 24 <br /> 3u <br /> TYPED OR PRINTED and'or ma:imw tmpnwnment of lwtwrn 6 month•and 5 Yeors 1 OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> IF IUD DISCHARGE OCCURRED DUPIi)G THIS REPORTING PERIOD REPOPT "NO DISCHARGE" <br /> y t <br /> _PA 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 19 EXHAUSTED <br />