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'ERMITTEE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved <br />'acdityName/Locatio '_dlferent) .., DISCHAR OIVITORIPIG REPORT/DA1R/ MB No.2040-0004 <br /> IAME_`- �_ a _'__-------- (2- 17-19 - approval expires9-30-85 <br /> PERMIT NUMBER DISCHARGE NUMBER <br />---- "--T------------ MONITORING PERIOD <br /> ACI LI TIC_ ---- YEAR MO DAY YEAR MO DAY <br />-OCATION I ! -- FROM TO <br /> (20-21 (22-23) (24-25/ (26-27) (28.29J (30-31/ NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION FREQUENCY PARAMETER 3 (46-53) (54-61) (38-45) (46.53) (54-61) NO. OF SAMPLE <br /> (32.37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62.63 (64.68) (69-70) <br /> 4 <br /> SAMPLE ' <br /> j ? MEASUREMENT <br /> PERMIT ; ,3+x ",'"q4"I'. a g 'z v <br /> i I REQUIREMENT <br /> + ' �• SAMPLE <br /> _ MEASUREMENT <br /> PERMIT :L ,•3'.. :+ og 4..?a a a w, q l ;f� a^ „ <br /> .. REQUIREMENT <br /> '• SAMPLE - <br /> i MEASUREMENT -• - <br /> • t PERMIT <br /> .y,, °f Y�.x,.,�. ,, e :>".,, C`..��' ', .x; a« f.. •w;,. <br /> REQUIREMENT ; ? •.� , <br /> SAMPLE - <br /> ' 1 MEASUREMENT <br /> PERMIT I r .d•w �.. M a w <br /> .. REQUIREMENT <br /> R L " �. ✓.J i. - SAMPLE - + <br /> 2 i MEASUREMENT , <br /> PERMIT " , t •a^ . - �, t, ..» "z , «. <br /> I REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t v . .;" ;' 9. %,,, <br /> w u, <br /> REQUIREMENT -- <br /> .. SAMPLE - <br /> MEASUREMENT <br /> ,. PERMIT ,v,, ..-»ys x.<, s •N 'aL. �.. <br /> •� ) .� y !. REQUIREMENT ,.. i °r ,. <br /> IAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE .ERso NALLY EX 1 ED 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 /> OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURATE AND COMPLETE• I AM AWARE THAT THERE ARE SIG- <br /> NIFICANT PENALTIE■ FOR SUBMITTING 'Al.. INFORMATION, IN CLVOING <br /> _- .----�- - THE PO Bs1BILITY OF FINE AND IMPRISONMENT, SEE IS U.S.C. I toot ANO SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 3 <br /> 1 U.s.e, g 1319. (Penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED and/or maximum imprisonment ofbetween 6 months and 5 years) OFFICER OR AUTHORIZED AGENT AREA <br /> CODE NUMBER YEAR MO DAY <br /> OMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> PA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED ( Pt,CL OF <br /> UNTIL SUPPLY IS EXHAUSTED. <br />