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PERMIT'S:E N ADDRESS (Include NATIONAL POLL' VT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> Facility NiOpt if¢ifferent) DISCH : MONITORING REPORT(DMR) OMB No.2040-0004
<br /> rr i:. .C1tV 11 ('a:� .3 ---------- (17-19) Approval expires 9-30-&
<br /> ADDRESS
<br /> ;•11tit''(+� ,.j.ALI" 1 PERMIT NUMBER DISCHARGE NUMBER
<br /> 1
<br /> ----1-------------------- MONITORING PERIOD
<br /> iIACILITY YEAR MO DAY YEAR MO DAY
<br /> LOCATION 1 ! FROM _ TO 1
<br /> (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
<br /> FREQUENCY
<br /> PARAMETER ! (46-53) (54-61) (38-45) (46-53) (54-61) EX An ALYsls STYPEE
<br /> (32.371 ; ><
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70)
<br /> 7 ! SAMPLE
<br /> i I MEASUREMENT
<br /> i ! 4
<br /> PERMIT
<br /> REQUIREMENT
<br /> SAMPLE >
<br /> MEASUREMENT -
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<br /> ' REQUIREMENT
<br /> SAMPLE
<br /> MEASUREMENT -
<br /> 'S �3 PERMIT k 1• . 4 > y+",, d••h cY,.aw .J�•'?} 4 '; w „%a „�w»MLo`ad
<br /> t ,,( REQUIREMENT i W'i 1'" t.
<br /> 1 t i A a^ SAMPLE
<br /> MEASUREMENT
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<br /> r"• `` a`�'1� { REQUIREMENT V el
<br /> SAMPLE T °
<br /> MEASUREMENT
<br /> PERM 1 T r !''. +, },�.' „ '!.r°Rt..„' sX`^a ,%i' r•i ✓s '.,k k- n.. « i �.s S_X Jf ti t` ,. z-
<br /> �: REQUIREMENT
<br /> SAMPLE
<br /> MEASUREMENT ��1
<br /> a. 1 PERMITH'• �.,, 4',•z,, w t�7�,•YY•,+'p.F i" j� f' .. di; ,'M,�C„ ;cj •+I.
<br /> ,77
<br /> REQUIREMENT ,• ti ! _ '• '
<br /> .. ,r .!,' �:°\.: •�. SAMPLE
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<br /> PERMIT .v a' t I, q: r •.e;..�v,Fyr.+.,r, ,.t'ff" 'ari+•ka"Y•za 4 ,•,ys° ..6 ,'� �F,1L
<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 INPOR MATION 1UBMITTEO HE
<br /> AND BASED
<br /> ON MY INQUIRY OP THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR -
<br /> Ir,' �• - OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION
<br /> IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG-
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING /
<br /> THE POSSIBI ITY OF FINE AND IMPRISONMENT. SEE IS U.B.C. 4 I00I AND SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> as U.S.C. g /SIS. (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 months and 5 years./ OFFICER OR AUTHORIZED AGENT AREA
<br /> CODE NUMBER YEAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> n 3320-1 (Rev. 10-79) UNTIL SUPPLY EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
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