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'ERMITTEE NAMEI'DDRESS (Include NATIONAL POLLUTA T ISCHARGE ELIMINATION SYSTEM(NPDL'S) corm Approved
<br />,acilityNameJLocati "fferent) DISCHAR ONITORING REPORT(D.W1R) M8 No.2040-0004
<br /> DAME—__t»•»- "' 1`•1-� —'_-----"---- 2-i 17.19 pproval expires 9-30-85
<br /> 4DDRE58 A
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<br /> PARAMETER i (46-53) (54-61) (38-43) (46-53) (54-61) NO. of SAMPLE
<br /> (32-37) 1 EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70)
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<br /> IAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY —.1... - TELEPHONE D A T E
<br /> ANO AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br /> ON MY IN O UIRY OF THOSR INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> r ' OBTAINING THE INFORMATION, I Bl LIB VB TH! SUBMITTED INFORMATION -
<br /> ` IS TRUE, ACCURATE AND coM"IST E. I AM AWARE THAT THERE ARE SIG- ,
<br /> NIPICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE IS U.B.C. 1 ISSI AND SIGNATUN'E OF PRINCIPAL EXECUTIVE
<br /> 33 U.s.c. g 131s. (Penalties under these statutes may include fines up to$10,000
<br /> ,TYPED OR PRINTED and)or maximum imprisonment ofbehveen 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT 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 CE UFED (HLPLACES EPA OR-d T-du WhICH MAY NOT GE U'.ED
<br /> UNTIL SUPPLY IS EXHAUSTED.
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