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PERMITTEE NAI DRESS (Include NATIONAL POLLUT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> FacilityNameJLoea iflerentJ DISCHAI IONITORING REPORT (DMR) OMB No.2040-0004
<br /> 1 2_ 17-19 Approval expires9-30-85
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<br /> FACILary I i 1 I i i
<br /> — 4 ----------- YEAR MO DAY YEAR MO DAY
<br /> LOCATION ! ! f FROM _ TO _
<br /> y (20-21) (22-23) (24-25) (26-27J (28.29) (30-91) NOTE: Read instructions before completing this form.
<br /> ! I (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> PARAMETER 1 I (46-53) (54-61) (38.45) (46-53) (54-61) NO. FR eDOVFENCY SAMPLE
<br /> (32.3�7) 1 I EX ANALYSIS TYPE
<br /> I ( 1 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS� )62.63 (64-68J (69.70
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<br /> NAMEITITLE 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 ING UIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR -
<br /> 7 1 OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION
<br /> .��` •' • IS TRUE. ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG-
<br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING '
<br /> THE Po SS IBIurY OF FINE AND IMPRISONMENT, SEE rS U.S.C. 3 loof AND SIGNATURE OF PRINCIPAL EXECUTIVE '7 Sa U.f-e. I uu. (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 NUMBER YEAR MO DAY
<br /> CODE
<br /> COMMENT AND EXPLANNATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> L 3, 1 i I i:.♦ .1 •t4 I .�' I r
<br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PACE o
<br /> UNTIL SUPPLY IS EXHAUSTED.
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