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PERMITTEE NA DDRESS (Include NATIONAL POLLUT DISCHARGE ELIMINATION SYSTEM(NI'DES) Form Approved <br /> FacilityNslne/Loca Ifferent).; DISCHA dON1TORING REPORT(D11R) OMB No.2040-0004 <br /> LI A IE 2 17.19 <br /> -- —.^------------ Approval expires 9-30-85 <br /> AflARESB ' <br /> '�.-� r(r*' i':,t.�•. PERMIT NUMBER DISCHARGE NUMBER <br /> I <br />---"-- --'--'—i---- ------ MONITORING PERIOD <br /> FACILITY_ I ! ______ -- <br />--•— ��—��•-- YEAR MO DAV YEAR MO DAY <br /> LOCATION ! !- FROM TO , <br /> L;r. k 'i Jry:-I f :,y (20-21) (22-23) (24.25) (26.27) (28-29) (30-31) NOTE: Read instructions before completing this form. <br /> I (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER ' J (54-61J NO. FREQUENCY SAMPLE <br /> (46-53) (54-61) (38-45) (46-53 <br /> (92-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 ( LY (69-70) <br /> P i SAMPLE <br /> i MEASUREMENT <br /> '`) •1' PERMIT n•;. r 1 F;a,, 5=,,1' -s if. 1, 'il „,,, ' <br /> t REQUIREMENT ' ;• :,w9 <br /> SAMPLE ' <br /> MEASUREMENT ' <br /> PERMIT , > ., ,.<. ,;�;:x'„ „ ;. -4• .,:2', �_ ...z,• °:.. <br /> REQUIREMENT - `` ✓:. y <br /> 2 <br /> SAMPLE •• 1 ..w. <br /> i MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> F t <br /> j. r•j,,. SAMPLE <br /> MEASUREMENT <br /> s PERMIT <br /> REQUIREMIENT , <br /> ..,. L; .. SAMPLE <br /> MEASUREMENT <br /> :PERMIT „F 1 fro=-$F°ro'^' •r ,<4'=? - ..w. - .. e .7 's <br /> L _ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT - - <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> 4 ON MY INQUIRY OF THOSE INDIVIDVALS IMMEDIATELY RESPONSIBLE FOR <br /> ' OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURATE AND COMPLETE„ 1 AM AWARE THAT THERE ARE SIG- , <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING ' <br /> THE PO SEIBILITY OF FINE AND IMPRISONMENT. SEE I$ U.S.C. I ISot AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> as U.S.C. g 1319. (penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED andJor maximum imprisonment of between 6 months and S 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) UNTIL SUPPLYEDITION <br /> IS EXHAUSTED„D (REPLACCS EPA :-ORM T-4r) I1C: MAY NOT BC USED.) <br />