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PERMITTEE NA ADDRESS (Include NATIONAL POLLU NT DISCHARGE ELIMINATION SYSTEM(NPDES) FO/rYlApprOVed
<br /> FaeililrNume/Lo fdijerent)- DISCH/ MONITORING REPORT(DAIR)
<br /> 17-19 - » t I : OMB No.20 expires
<br /> 9-4
<br /> ,--� L ?r=--`-�----�— --.---- k" t Approval expires 9-30-85
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<br /> ------"-- ------ MONITORING PERIOD
<br /> FACILITY
<br /> --�--'—a'�^.---�------------ YEAR MO DAY YEAR MO DAY
<br /> LOCATION ( FROM ;1
<br /> 4 TO
<br /> T '. '•I ;!':»f " "' '� ',,;'• ^ t (20.21) (22.23) (24.25) (26.27) (28-29) (30.31) NOTE: Read instructions before completing this form.
<br /> ? (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> PARAMETER (46•S3J (54-61 NO. SAMPLE
<br /> FREQUENCY
<br /> 1 (38.4S) (46.53) (S4-61) Or
<br /> (32.37) EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63 (64-68) (69-70)
<br /> SAMPLE
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<br /> NpUG•y�Y t,� SAMPLE }� 131t1f35
<br /> MEASUREMENT
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY Or 1.—THAT I HAVE IERSONA LLY ExAMINED f TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br /> f� i� ON MY INQUIRY Or THO.- INDIVIOUALf IMMEDIATELY Rid/ONfIBL. "OR
<br /> M
<br /> OETA ININO THE INFORMATION, I BELIEVE THE 11—ITTILD IN rORMATION ut,``^^ 't ,,\1�"a'y °I r'r(�, •{/'�L
<br /> r I. TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG.
<br /> NIFICANT PENALTIES POR SUBMITTING FALSE INFORMATION, .—UDING
<br /> �� ,,�-y I{)/.—>♦�r`r THE POSSIBILITY Or FINE AND IMPRISONMENT, SEE 14 U.S.C. 4 toot AND ( .' Z'• !-1� r-� /,
<br /> I uI Y^•f ` „
<br /> U.S.e. 0 13,9. (Penalties under these statutes may include fines up10$10,000 SIGNATURE OFPRINCIPALEXECUTIVE
<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 EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> S 7 `
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<br /> ..,'tom ( 1 °'/3�';r•a. a .`�,. ". -. 7
<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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