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PERMITTEE NAMF DRESS (Include NATIONAL POLLUTA' 131SCHARGE ELIMINATION SYSTEM(AIPDES) Form Approved <br /> 7acllityName/Locati -fferent) DISCHAR ONITORING REPORT (DSMRI <br /> vAME " m. 3 ' t' t 2-. 17-19 IMBNo.2040-0004 <br /> , <br /> h - ------------_ Approval expires 9-30-85 <br /> —� I ------------ <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ' 1 1 <br /> ---- t _T_----------- MONITORING PERIOD <br /> FACILITY <br />----�t�—^-------------- YEAR MO DAY YEAR MO DAY <br /> LOCATION )1 j FROM - TO <br /> (20-21) 122-23) (24-25) (26-27) (28-29) 130-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION FREQUENCY PARAMETER NO. SAMPLE <br /> (46-53) (54-61J (38-45J (46-53J (54-61J OF <br /> (3237) Ex TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70) <br /> SAMPLE <br /> . MEASUREMENT <br /> PERMIT <br /> REQUIREMENT s• 1 <br /> SAMPLE t <br /> ( -•+ �: 'i MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> .p .. •.,L..C;_,. + SAMPLE ..( <br /> • 1 , », +, 1, •^- I -. I MEASUREMENT <br /> PERMIT ,. + ''•: n ,..:,f ':�-;>*' ,"a"'. ,9 4"ro ., ,»( ., <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMITS {.., „H ,n •. 1 r•' k ! •4 Id „ <br /> 4 1 .+_ s- 1 REQUIREMENT <br /> ;•t'..y . ..S. 1.., SAMPLE <br /> MEASUREMENT <br /> 1 I PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> VAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> ANO AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIDLE FOR _ <br /> OBTAINING THE INFORMATION, 1 BELIBVK THE SUBMITTED INFORMATION <br /> Is TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARK SIG- <br /> . NIPIC qNT PENALTIES FOR SUBMITTING FALSE INFORMATION. INCLUDING <br /> THE rOSe18ILITY OF FINE AND IMPRISONMENT. !KE I$ U.S.C. 5 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 93 u.s.e, g 13IS. (Penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 mon thsand S years.) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br />:OMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />:PAPREVIOUS F.^IT!ON TO OE U"�D <br /> orm 3220-1 (Rev. 10-79) (..::-: ,.c s :-. „ �,.:., ,-_ �Y :,_. _. .. —•1 <br /> UNTIL SUPPLY IS EXHAJSTED. <br />