Laserfiche WebLink
:RMITTEE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) orm Approved <br /> c;lityName/Location ferent) DISCHARG' ONITORING REPORT(DMR) IS No.2040-0004 <br /> AM E I� '' '' 2-1 17-19 _ jproval expires 9-30-85 <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> C 1 p I <br />-----=� — ----------- MONITORING PERIOD <br /> ncluTv I <br /> -�!-T------------- YEA I YEAR MO DAY <br />;;CATION FROM TO r <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 FREQUENCY <br /> PARAMETER (46.53) (54-61) (38-45) (46-53) (54-61) No. OF SAMPLE <br /> (32.37) EX ANALYSIS TYPE <br /> i 1 1 1 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62.63 (64-68) (69.70) <br /> 1 <br /> SAMPLE , <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - r <br /> MEASUREMENT <br /> + PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT . <br /> r <br /> ' tt SAMPLE - <br /> L � y MEASUREMENT 1 <br /> a..,•� PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> T _ MEASUREMENT <br /> i I_n 1 ..1 w i• - <br /> PERMIT <br /> REQUIREMENT i <br /> 1 <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> t <br /> ,; -�•, SAMPLE - •- <br /> '�� MEASUREMENT <br /> f1 PERMITy- <br /> - REQUIREMENT •" "`'� " <br /> AME/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 ON MY IN <br /> O UIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION+ I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE 510- <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE FORMATION, INCLUDING ' <br /> ^ _ THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE n U.S.C. 1 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> as u s.c, g 1 ale. (penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 mon Ills and 5 years) OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MO DAY <br /> IMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />'A Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHIc-Y MAY NOT OE t15s D ) = O <br /> UNTIL SUPPLY IS EXHAUSTLO. , <br />