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PER-41TTEE ADDRESS (Include NATIONAL POLLUTAN CHARGE ELIMINATION SYSTEM (NI'Uflb) proved. <br /> Fa-ht) Nome n if dt7erent) DISCHARG IITORING REPORT (U41R) .2040-0004 <br /> NAME _ _ (=-1 (17-19) provd expires 9.30-85 <br /> -- ----------------- r1 <br /> ADDRESS--- - - "' - OVA <br /> t' <br /> F I — PERMIT NUMBER DISCHARGE NUMBER <br /> ———————————————————————— MONITORING PERIOD <br /> FACILITY ---_ YEAR MO DAY YEAR MO DAY <br /> LOCATION ------- FROM C•� ICJ, l+N TO C7 1 06 3/r <br /> -------"----------- Cam: V't 5� U l l <br /> (20-21) (22-23) (24-25) (26 27) (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. FREQDUF NCY SAMPLE <br /> (3237) EX ANALYSIS TYPE <br /> pprr tt C. AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63) (6468) (69-70) <br /> SAMPLE <br /> 68 �' C VISUP1 MEASUREMENT PERMIT r� <br /> 84066 1 U REQUIREMENT if V.3 . I E.l <br /> �=Vis{b tile <br /> 1 SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERM 1 T <br /> REQUIREMENT <br /> n SAMPLE <br /> I MEASUREMENT <br /> N <br /> l(7 <br /> PERMIT <br /> REQUIREMENT, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> I MEASUREMENT <br /> o_ <br /> PERM IT <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 /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> Dames S. Lunan OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> Manager - Permits NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IB USC 4 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE 7 <br /> 33 USC 41319 tPenalbrn under these slatut- na Include fine, up I,, Srtt INXI — <br /> TYPED OR PRINTED and or ma:mlum In,p—,,nrn,w o/hetuven 6 month.and i wan I OFFICER OR AUTHORIZED AGENT CODE <br /> AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> } <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 />