Laserfiche WebLink
'ERMITTEE NAMF DRESS (Include NATIONAL POLLUTA ISCHARGE ELIMINATION SYSTEM(NPDES) <br />"acilityNanxe Locali ferent)'. 1_.� y _ DISCHAR ONITORING REPORT lDbfR) _ <br /> 2-1c 17-19 <br /> (:1't`_` ��".' {'f'•r! 'J PERMIT NUMBER OISCHARGENUMBER <br />_--- „ <br /> ----------------- MONITORING PERIOD <br /> RACIL.ITY -- --- YEAR MO DAY YEAR MO DAY <br />_OC ATION FROM TO { ' <br /> W `'(r'1< (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 NO FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54-6/) (38.45) (46-53) (34�1) OF <br /> (32-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (62-63) (64-68) (69-70) <br /> SAMPLE <br /> tS J MEASUREMENT <br /> PERMIT <br /> i 7 ": . r I. 'REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> t'�RM tT <br /> REQUIREMENT <br /> SAMPLE • <br /> MEASUREMENT <br /> PERM IT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> 1 <br /> PERMIT � .. <br /> REQUIREMENT,, <br /> SAMPLE, <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> RED U I REM E FIT <br /> SAMPLE <br /> MEASUREMENT <br /> P£RMtt ' <br /> a EQtJ I REM EMT <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 /> -4C ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR ^,r <br /> OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION <br /> ^' IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG �••' 'r i <br /> I ti,.1`'/v! NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> 1" <br /> THE POSSIBILITY OF FOR <br /> AND IMPRISONMENT SEE 18 USC 11001 AND SIGNATURE OF PRINCIPAL EXECUTIVE , <br /> 33 USC 4 1319 tPvn.1ne, under thew etatule., ma, —Il de fin- up 0, E10000 <br /> TYPED OR PRINTED alai ur maximum Inlpnwnmrnt 4 hri—en fi munthr and.5 want OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all atia(hments here) CODE <br />:PA Form 3320-1 (Rev. 10-79) UNTIL SUPPLY EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />