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PERMITTEE NAM DDRESS (Include NATIONAL POLLUT DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> FacllityName(Loca ifferent) DISCHAI IONITORING REPORT(DMR) OMB No.2040-0004
<br /> NAME 2- 17-19
<br /> L Approval expires9-30-85
<br /> ADDRESS
<br /> 1 1 ._•�..� 1T,- PERMIT NUMBER DISCHARGE NUMBER
<br /> 1_AGILITY # I I MONITORING PERIOD
<br /> —�T ---------- YEAR MO DAY YEAR MO DAY
<br /> LOCATION 1 1 t r_1 FROM TO
<br /> ,• J r (20-21J (22.23J (24-25) (26-27) (28.29) (30.31) NOTE: Read instructions before completing this form.
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<br /> PARAMETER (46-53) '(54.61) (38-45) (46-53) (54-61) or
<br /> (32-37) • EX ANALYSIS TYPE
<br /> s AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62.63 (69-68) (69.70)
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CKRTIFY UNDS:R FBNALTY OP LAW THAT I NAVC PERSONALLY KXA MINKD TELEPHONE D A T E
<br /> AND AM PAMILIAR WITH THK INFORMATION lVBMITTCD HKRSIN AND ■ASKD -
<br /> ON MY INQUIRY OP THOSK INDIVIDUALS IMMKDIATB LY RK SFONSIB LK POR '
<br /> � �( A OBTAINING THK INFORMATION, I BBLIKVK THK SUSMITTKD INFORMATION
<br /> .rJ•T�r 1�-�-``V I- 19 TRUE, ACCURATE AND COMPLETE, $ AM AWARE THAT THBRB ARK SIG-
<br /> NIPICANT PENALTIES FOR SUBMITTING FALSK INFORMATION, IH CLUOING „ % '
<br /> ' THE FOSS IBI LITT OF PINE AND IMPRISONMENT. SEK 16 U.S.C. 4 1001 AND
<br /> 93 U.s.c• g 1019. (Pena/ties under these statures may include fines up to$10,000 SIGNATURE OF-PRINCIPAL EXECUTIVE
<br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 months and 5 years) OFFICER OR AUTHORIZED AGENT AREA ' NUMBER 'r 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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