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'ERMITTEE NAME `DRESS (Include NATIONAL POLLUTAN nISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> acilityName/Locetit ferent) DISCHAR, ONITORING REPORT(LIMR)
<br /> 11ME—,— _E• I+' ' —_— I _ MB No.2040-0004
<br /> 2-1 17-19
<br /> —.,� �� ---- pproval expires 9-30-85
<br /> PERMIT NUMBER DISC-AR-.NUMBER
<br /> MONITORING PERIOD
<br /> YEAR MO DAY YEAR MO DAY
<br />.00ATION �� + FROM TO
<br /> (20-21) (22-23) (24.25) (26.27) 28.291 (30-31J NOTE: Read instructions before completing this form.
<br /> f (3 Card OnlyJ QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> PARAM TL!R (46.53) (34.61 FR[OUENCY
<br /> / (38.45J /46.53J (f¢6/J NO, of SAMPLE
<br /> I (i7.3TJ I EX ANALYSIS TYPE
<br /> I I AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62.63 (64-68) (69-70)
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<br />[AMC/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 /> ON My INQUIRY OF TryO.E INDIVIDUALS IMMEDIATELY REf PON11E LE FOR '
<br /> ,. r, `•, " i`• , OSTAININO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION ,
<br /> 16 TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE ■10- -
<br /> NIFICANT PENALTIES FOR SUEMITTINO FALSE INFORMATION, INCLUOINO
<br /> „1•. ', _' '_f THE PSSIBILITY OF FINE AND IMPRISONMENT. SEE It U.E.C. I IQ01 AND
<br /> 1 as U.EO.C. I IS/S. (Penalties under these statutes may include fines up to$10,000 SIGNATUPi'E OF PRINCIPAL EXECUTIVE
<br /> TYPED OR PRINTED and(or maximum imprisonment of between 6 months and S years) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br /> CODE
<br /> OMM ENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br /> rm 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTIL SUPPLY IS EXHAUSTED.
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