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PERMITTEE NA DDRESS (Include NATIONAL POLLUTA T DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> FacilityName/Loca different) DISCHA) MONITORING REPORT (DMR) OMB No.2040-0004
<br /> NAME 1, - 2 17.19 Approval expires 9-30-85
<br /> ADDRESS
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<br /> --� - PERMIT NUMBER DISCHARGENUM.ER----- ---------=— MONITORING PERIOD
<br /> YEAR MO DAY YEAR MO DAY
<br /> LOCATION _T P 1 �_------ ----- FROM TO
<br /> (20-21) (22-23) (24.25) (26.27) (28.29) (30-31) NOTE' Read instructions before completing this form.
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<br /> ` 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 IENALT* OP LAW THAT 1 HAVQ 1-SON ALLY EXAMINED TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INPOR NATION eVBMITTlD HEREIN AND BASED
<br /> JJ/ ON MY INQUIRY OP THOSE INDIVIDUALS IMMEDIATELY RESPONSIELE FOR
<br /> �'O{{1„j > k I:.��Ii` M'✓�, DST A INING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIO-
<br /> NIPICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING • • j,• �� ,)
<br /> THE FO SSIBILITY OF FINE AND IMPRISONMENT. SEX 1e U.S.C. f 1001 AND
<br /> as u.e,c. § Sin. (Penalties under these statutes may include fines up to$10,000 SIGNATURE OF PRINCIPALEXECUTIVE y( 1 ate — '? L�,-'I
<br /> TYPED OR PRINTED andJor maximum imprisonment oflietween 6 months and 5years.) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO _ DAY
<br /> CODE
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<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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