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PERMITTEE N ADDRESS(Include NATIONAL POLL T DISCHARGE ELIMINATION SYSTEM(NPD6S) Form Approved
<br /> FaeilityName/so fdifferent/ , DISCHJ MONITORING REPORT(Dh7R)
<br /> NAME Mom;_;. ik,1 '"�' '` ' 17.19 OMB va 2 pines 9-3
<br /> _ ! �•,:•:�---., , -------- � Approve/expires9-30-85
<br /> PERMIT NUMBER DISCHARGE NUMBER -
<br /> ---- ------------ MONITORING PERIOD
<br /> MACIL.ITY I !
<br /> --�-- -- VCAR MO DAV VCAR MO DAY
<br /> LOCATION FROM ,TO
<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
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<br /> (46-53/ (S4.61J (38-45J (46.53) (54-61) OF
<br /> I (32-3� i i EX ANALYSIS TYPE
<br /> II AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69.70)
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY cxAMINSO - - - - TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED'! - ,
<br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR y
<br /> OBTAINING THE INFORMATION, I ■KLIZVX THE SUBMITTED INFORMATION
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG- r Lf
<br /> N IFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING - 1
<br /> - THE PO ff IBIL1TY OF FINE AND IMPRISONMENT. SEE n U.B.C. 4 1001 AND- SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> �l r- -- - -•--� 21 U.S.C, g nu. Penalties under these statutes may(Penalties Under y include fines to 510,000•
<br /> TYPED OR PRINTED andlor Maximum imprison ment of between 6 months and S years,) "" OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> EPA Form 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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