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PERMITTEE NA 'ADDRESS (Include NATIONAL POLLU DISCHARGE ELIMINATION SYSTEM(A�PDES) Form Approved <br /> Facility A'ame1Loc different) DISCHA MONITORING REPORT (DMR) OMB No.2040-0004 <br /> NAME— ^•,I ' i ' '- :, _ _------- 17-19 Approval expires 9-30-85 <br /> ADDREiR -- w`-i'` j <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> atACILITv— !— ----------- MONITORING PERIOD <br /> ' ----------- YEAR MO DAY YEAR MO DAY <br /> LOCATION j j FROM TO - <br /> i (20-21) (22-23) (24.25) (26-27) (28.29) (30-31) NOTE: Read instructions before completing this form. <br /> f I I (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) ry0, FR EOOFNCY SAMPLE <br /> i (32-37) , I EX ANALYSIS TYPE <br /> t AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64.68) (69-70) <br /> SAMPLE .. „ <br /> MEASUREMENT <br /> PERMIT " <f;i "r' Z, <br /> REQUIREMENT <br /> -' :.+C ^- H• SAMPLE - - <br /> Yfry� MEASUREMENT <br /> PERMIT li, 4 •';, �' -. '•r'i:ir'$u'1 y:.,'r. '%yYR,1es',w•..,,y. - M ,y ->r :j3 "0 s'*" ,'! %v , <br /> ,y t REQUIREMENT gr A, , <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT , <br /> SAMPLE ' <br /> MEASUREMENT <br /> ' PERMIT 7777dt - <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY iXAMINEO TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> i ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> - OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION - -IS TRUE,NT ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIQ- <br /> ' NIFICAPENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING ' <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT, ■EN 1• U.S.C. 4 1001 AND{ IGNATUPi'E OF PRINCIPAL EXECUTIVE 03 U.S.C.U.S.C• 3 1319. (Penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED end)or maximum imprisonment of between 6 months and 5 years I OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attach men tshere) <br /> EPA Form 3320-1 (Rev. 10-79) UNTIL UPPL I II XHABE USED (RE-PLACES EPA FORM T-40 V:IviCH MAY NOT CC USED j pr OI- <br />