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[IR C <br /> E88 ___ �I --��C T I'a----- l Z � S <br /> AD <br /> _--- ----,� DISC NARGE NVMBCa ` <br /> ---- —• _t --------------- MONITORING PERIOD <br /> FACILITY--------------------- YEAR MO DAY I AR MO DAY <br /> LOCATION FROM I I TO <br /> (20-21) (22-23) (24.23) (26 ) (28.29) (30.31) NOTE: Reed Instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (18-45) (46-51) (54-61) NO. FREOUENCY SAMPLE <br /> OF <br /> (32 37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITE MINIMUM AVERAGE MAXIMUM UNITS 62-63) (64-8) (69-70) <br /> SAMPLE <br /> FL (FFFLI.t,. T) MEASUREMENT NO DISC RGE <br /> PERMIT I' G. -• , <br /> REQUIREMENT <br /> cT <br /> SAMPLE <br /> T ,T- ` `I11F MEASUREMENT * e <br /> �• — <br /> (EF L,•E ' T) PERMIT L3 ;,G/L <br /> • 3 REQUIREMENT * * « * * 7r )k * * 1M # ttt Z 7 Q 1/3 n G q <br /> T ♦ SAMPLE <br /> I° (� 1 �; 1 . L MEABUREMENT k + * * # <br /> L5 REQUIREMENT 3 0 GR <br /> SAMPLE <br /> PHeFIELD MEASUREMENT * * * * * * * * * # <br /> C ) PERMIT 9U <br /> E REQUIRMENT I 3cl GR <br /> w <br /> �1 <br /> SAMPLE <br /> DIL d G•�Era-E MEASUREMENT <br /> v 1S L'.,L PERMIT r - +4/L <br /> II'1 2 HSOUIRII,MENT fi llr 1r * 11 * * * llf * * * Tk 1}' * {� 1/3 D VI <br /> SAMPLE <br /> i✓•JCTJ4ITY x,/ MEASUREMENT <br /> Y.Jz4 (EFFLt,F:''rl PERMIT <br /> 7 q + I. REQUIREMENT fi GA <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 /> Jay Hednick OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> 15 TRUE ACCURATE AND COMPLETE 1 AM AWARE THAT THERE ARE SIG <br /> Hydrogeologist NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IS USC 1 I001 AND O3 337-5903 4 2 <br /> 37USC 11319 rPrnallR, uralrr Ihrr nerutr, nlav mrladr /Inr, up lu llu rtrXr SIGNA E OF PRI CIPAL EXECUTIVE <br /> TYPED OR PRINTED ard•nr metlm arrl Impn,rmmrnt o/hrtlwrn 6 month,and S vro r,I OF ER OR AUTHORIZED AGENT CODE <br /> NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> IF f�11C—.'IGE r.CC0PhEG LA.-RI ,G THIS RFPCRTIi•,G PEriIC_' PEPC-RT "'.G DISCHARGER <br /> t � <br /> EPA Form 3320.1 (Rev. 10-79)PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) PAGE OR <br /> UNTIL SUPPLY 18 EXHAUSTED <br />