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°ERMITTEE NAM RESS (Include NATIONAL POLLUTA° ISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br />'acilityName)Locati ferent) I DISCHAR ONITORING REPORT (DMR) M8 No.2040-0004
<br /> 2.1 17-19 - pproval expires 9-30-85
<br /> PERMIT NUMBER DISCHARGE NUMBER
<br />---- -- MONITORING PERIOD
<br /> 1'ACILITY_ ?
<br />--- �r ��—�---------- YEAR MO DAY I YEAR MO DAY
<br />_OCATION i - -_� FROM LL TO
<br /> (20-21 (22-23) (24.25) (26-27 ) p 9
<br /> ) (28.29) 30-31 NOTE: Read instructions before com letin this form.
<br /> i (3 Card Only) QUANTITY OR LOADING 14 Card Only) QUALITY OR CONCENTRATION FR[au[Ncr
<br /> PARAMETER I (46-53) (S4.61) (38-45) (46-53) (54-61) No. of SAMPLE
<br /> I (f-37) I EX ANALYSIS TYPE
<br /> 1 !1 11 1 i AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69.70)
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<br /> N '•
<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER 'KNALTY OF LAW THAT I HAVE FERSONALLv EXAMINED - TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH TNH INFORMATION SUBMITTED HEREIN AND EASED
<br /> ON MY INQUIRY OF THOSE INDIVIDUAL! IMMEDIATELY RESPONSIBLE
<br /> NfiB LH FOR-
<br /> OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION - -j .r
<br /> f IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG- /1 F
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br /> THE to S■IBILITY OF FINE AND IMPRISONMENT. SEE 1S U.S.C. I I-I AND
<br /> SIGNATU N'E OF PRINCIPAL EXECUTIVE
<br /> » U.S.C. 4 lalf. (Penalties under these statutes may include Ernes up to$10,000
<br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> I Y't
<br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USFD (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTIL SUPPLY IS EXHAUSTED.
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