PERMITTEE NA DDRESS(Include NATIONAL POLLU DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> Facility Name/Loc, different) DISCHA MONITORING REPORT(DhIR) OMB No.2040-0004
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<br /> r Approval expires 9-30-85
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<br /> �• YEAR MO DAY YEAR MO DAY
<br /> LOCATION --_----------_ FROM ! TO
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<br /> } (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION FREQUENCY PARAMETER ' (46-53) (54-61) '(38-45J (46-53) (54-61) NO. OF SAMPLE
<br /> (32.37) _ 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 EXAMINED TELEPHONE D A T E
<br /> AND AM PA MILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED /{
<br /> ON MY INQUIRY OP THOSE INDIVIDVALS IMMEDIATELY RESPONfI■LE POR - .�
<br /> 1 ( OBTAIN... THE INFORMATION, I BELIEVE THE SUBMITTED INPORMATION
<br /> � Y�I+� ,�K.w y'�•.''..- IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG-
<br /> Y NIPICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLVDING
<br /> ,..ti THE POSSIBILITY OP FINE AND IMPRISONMENT. SEE 19 U.S.C. § 10.1 AND
<br /> 33 us.c. § 1319. (Penalties under these statutes may include fines up to$10,000 SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> TYPED OR PRINTED andJor maximum Imprisonment of between 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MO DAY
<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 BC USED (RCPLACES EPA F-ORM T-40 WHICH MAY NOT DE USED.) PAGE OF
<br /> UNTIL SUPPLY IS EXHAUSTED.
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