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PERMITTFE DDRESS Oruh,d, NATIONAL POLLUTANT HARGE ELIMINATION SYSTEM (NPD1,S) raved <br /> Factlt.j hame n if d0jerent) DISCHARGE ITORING REPORT Il)SIR) .2040-0004 <br /> N.#id E (/7-/9) <br /> e/expires 9-30-85 <br /> ADDRESS � - ' <br /> ------------------------ <br /> .- 1 ^. - PERMIT NUMBER DISCHARGE NUMBER <br /> ------------------------ MONITORING PERIOD <br /> FACILITY ———————————----_ YEAR MO DAY YEAR MO DAY <br /> -------- <br /> LOCATION FROM - TO <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) (46-53) (54-61) NO. FREQQUFNCY SAMPLE <br /> (3237) <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> >< (62-63) (64.68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ." C ,( i�1 rf 4,/ t'1 <br /> '4666 I 1, REQUIREMENT 1 <br /> t C ^1 <br /> SAMPLE .. <br /> `� MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> C') MEASUREMENT <br /> -. <br /> 1 <br /> N , <br /> W PERMIT <br /> REQUIREMENT, <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> J1 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 �1 <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR / <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> Farces S. !uncn _ <br /> r' IS TRUE ACCURATE ANO COMPLETE I AM AWARE THAT THERE ARE SIG <br /> re T,�1} NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> Mo nQ ae - r S THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 U S C 4 Ill AND rr'' ) L� <br /> 33 US S 1319 IPenalne, under th-e statute, ma% Inrlude /Inv. up fo fln tXwl SIGNATURE OF PRINCIPAL EXECUTIVE VVL /�4—�LJ? ��/ �/ L�li <br /> TYPED OR PRINTED and—ni.—u ilmpnnu—,w,,/M•Iuwen 6month.ond5 ware OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference till 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 />