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PEPMITTEE NAM RESS (Include NATIONAL POLLUTANT D RGE ELIMINATION SYSTEM (NPDF.S) For ad. <br /> Facility Name/Lo 6Ferenr) t DISCHARGE I ORING REPORT(DA1R) OM IO-0004 <br /> (2-I6) (17-19) Approv xpires9-30-85 <br /> ADDRESS <br /> _•,_ <br /> I(i.::..1TA' PERMIT NUMBER DISCHARGE NUMBER <br /> ———————————————————————— MONITORING PERIOD <br /> FACILITY—_—, — -- YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM TO <br /> ------------------------- % <br /> (20-21) (22-23) (24-25) (26 27) (za-z9) (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_ FREQUENCY SAMPLE <br /> OF <br /> (3237) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63)I (64-68) (69-70) <br /> n (.T S'd hL SAMPLE (� =k X •' •, 1,r�r� ,r7 <br /> 1..i MEASUREMENT Y <br /> t 1 <br /> U REQUIREMENT <br /> S, <br /> j4C):; I () PERMIT <br /> # _ -^ T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE tl <br /> MEASUREMENT 1 <br /> U <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 /> ON MY INQUIRY OF THOSE INDIVIDI/ALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 1 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 USC 11319 ,Pvna l mn Ir..Ih,nr. ruL•. rh.•.v �rarut.•. lou" up o, Elrl nnn u � • <br /> TYPED OR PRINTED u,ut ,,,,nn,,,,u,,",.....nm,nr,d h.ru..n 6nn.nrh..rnd �..•n.., OFFICER OR AUTHORIZED AGENT CAREA <br /> ODE NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS IRelerrn— all anuchnlentc 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 15 EXHAUSTED <br />