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PERMITTEE NA] DDRESS {Include NATIONAL POLLUT DISCHARGE ELIMINATION SYSTEM(APDESJ Form Approved <br /> FacilityNctne/Loca If['erent) 1; DISCHAI IONITORING REPORT (DAIR) OMB No.2040-0004 <br /> Approval expires9-30-85 <br /> ADDRESS' <br /> '"•' �'�.'��- �� j PERMIT NUMBER DISCHARGE NUMBER <br /> t�AClury � ' <br /> ---------- MONITORING PERIOD <br />-----'--+-'�-��------------ YEAR MO DAY YER MO DAY <br /> A <br /> LOCATION y ' FROM TO - , <br /> -r v (20-21) (22-23J (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 <br /> PARAMETER 46-53 NO. SAMPLE <br /> ( ) (54-61 J (38-45J (46-53J (54-61 J FREQUENCY OF <br /> (32-371 ! EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62.63 (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> P E I MIT , ,,is'. - - - '' ., , .. . $• < - -_. y., - <br /> £. REQUIREMENT s� -,s %, - ,• <br /> SAMPLE ' <br /> • ;t^,� MEASUREMENT <br /> PERMIT <br /> ' REQUIREMENT <br /> • .. - SAMPLE - - --i <br /> } y MEASUREMENT <br /> •- PERMIT } s• ,. ., ,,-+; .: - +_lM <br /> REQUIREMENT <br /> I <br /> ' - SAMPLE ' <br /> L MEASUREMENT <br /> PERMIT j y,„ ,;;', _ , •. { _ - <„ <br /> 1 REQUIREMENT <br /> <._. SAMPLE <br /> MEASUREMENT <br /> t d REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> 4 - ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OP LAW THAT I HAVE PERSONALLY S.A.INEO TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ON MY INQUIRY OF THOSE INDIVIDVALS IMMEDIATELY gESPONStG LE FOR _ - <br /> �" OBTAINING THE INFOq MATION, I BELIEVE THE SUBMITTED INFORMATION <br /> IS TWUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG- <br /> ( NIPICANT PENALTIES POW SUEMITTING FAL.. INPUR MATION, IN L-LUDINO <br /> • __ __ __ rHe Po SS1EILITY OF PINE AND IMPRISONMENT, SEE IS U.S.C. 4 1001 AND <br /> r 13 U.S.C. g 1310. (Penalties under these statutes may include fines up to$10,000 SIGNATURE OF PRINCIPAL EXECUTIVE <br /> TYPED OR PRINTED andJor maximum imprisonment of between 6 months and 5 years) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (;;_PLACES EPA t 07',14 1' 40 '.^J'1,C7i MAY NOT L E USED.j <br /> UNTIL SUPPLY IS EXHAUSTED• -- "' <br />