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PERMITTEE NAM DRESS (Include NATIONAL POLLUTA ISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> FacilityName)Locati ';/erent) D►SCHAR ONITORING REPORT(DAIR) MB No.2040-0004
<br /> NwnaE <'C+'w1 f _,1 2• 17-19 - s i pproval expires 9-30-85
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<br /> YEAR MO DAYI YEAR MO DAY )
<br /> LOCATION i 3 h i „ FROM TO
<br /> =`ti 1i 1'W z 7\I : s ,';`I (20-21) (22-23) (24.25) (26.27) (28-29) 130- 1) NOTE: Read instructions before completing this form.
<br /> 1 i ? (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION rRcouencr
<br /> PARAMETER i , • (46.53) (34.61) (38-45) (46-53) (54.61) NO. cF SAMPLE
<br /> (32-3,7).1 EX ANALYSIS TYPE
<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 PENALTY OF LAW THAT I HAVE PERSONALLY —MINED TELEPHONE D ATE
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br /> tt cc ON MY INQUIRY OF THOSE INDIVIDVALS IMMEDIATELY RESPONSIBLE FOR
<br />'s<1 �L«jV nt �'W V�•' ` OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION A "
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG-
<br /> NIPICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING 'Q 1 fr�,.�•'�.^"'
<br /> ' THE POSSIBILITY OF PINE AND IMPRISONMENT. SEE IS U.S.C. 1 1001 AND
<br /> as u.B.c. y 1019, (penalties under these statutes 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 YEAR MO DAY
<br /> CODE
<br />=OMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) ,
<br /> Li e"S�l F�4:
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<br />:PA Foim 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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