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PERMITTtE NAM S (Include NATIONAL POLLUTANT DI !GE ELIMINATION SYSTEM (.\'PULJ) form d <br /> Facd,.1 Aame/Lucan erenr) DISCHARGE M ORING REPORT iDAIR) OMB No. I-0004 <br /> N.,M E——_— ——————————— (?-!6 I (17-19) Approve/expires 9-30-86 <br /> ADDRESS •- <br /> -- PERMIT NUMBER DISCHARGE NUMBER <br /> ———————————————————————— MONITORING PERIOD <br /> FACILITY I•- <br /> ------------------------ YEAR MO DAY E DAY <br /> LOCATION FROM TO YAR MO <br /> (20-21) (22-23) (24-25) (2627) (28-29) (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) (34fi1) NO. SAMPLE <br /> OF <br /> (32-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< (62-63) (64-68) (69-70) <br /> _ SAMPLE <br /> MEASUREMENT '� ,. <br /> PERMIT <br /> 1 0 REQUIREMENTr'C'/' �r <br /> SAMPLE <br /> 'S MEASUREMENT * �' <br /> r' PERMIT r� <br /> 3G i V REQUIREMENT tf y. 01 GR <br /> SAMPLE <br /> IRON MEASUREMENTPERMIT <br /> * x <br /> 1045 1 O REQUIREMENT <br /> 01/sfl GR <br /> SETT. <br /> N <br /> SETT. SOL MEASUREMENT <br /> U <br /> PERMIT 0PTV10N 01/30 GR <br /> 545 1 O REQUIREMENT Y. �' �: <br /> SAMPLE <br /> HE MEASUREMENT s< * 7k <br /> r PERM <br /> U 01�/90 GR <br /> REQUIREMENT ti: � <br /> SAMPLE <br /> MEASUREMENT Vr <br /> r�/ PERMIT n 7 r <br /> 400 1 0 REQUIREMENT r)1/U/ �7R <br /> �r ff� SAMPLE ti V <br /> C• 1 4 MEASUREMENT �' z <br /> GG !; PERMIT R�(�R n r� rr� <br /> 556 1 U REQUIREMENT '' * OF(l•:Uii 1 L' 01/07 GR <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 /> 1.,r� J ( ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> Ci1111_ S:. Luilan OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> r' y.r _ IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG ) S <br /> ref ril L NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING _ <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IB USC 4 1001 AND I C` C VI; <br /> 33 US 41319 rPrnalnr. ural.•. rhr.r >,mrum. n . mclLd, /ur,•. up o, ttu nuu SIGNATURE OF PRINCIPAL EXECUTIVE t.UL .-/4-J[,r.." `�% [/ <br /> TYPED OR PRINTED and m mavmum rmpn.un m.nt n/hr to rvn 6 month,and i Ivor., OFFICER OR AUTHORIZED AGENT AREA <br /> D NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments 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 />