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PERMITTEE NAM DRESS (Include NATIONAL POLLUT ISCHARGE ELIMINATION SYSTEM(NPDES) orm Approved <br /> FacilityMme/Loeati fferent) DISCHAR ONITORING REPORT(DMR) MB No.2040-0004 <br /> NAMEX t• ' '�'- i I i•--�---- 2- 17-19 I- — 1 ,pprovel expires 9-30-85 <br /> ADDRESS V .1=------------ - . _ - :, , M L F. i .. :. *' ,. �• .t.. - �..3 T:�! . . -� <br /> `..•,rrti,4••i,i r -- PERMIT NUMBER OISCHARGENUMBER <br />---- ° --------- MONITORING PERIOD <br /> _ i 1 <br /> FACILITY I YEAR MO DAY I YEAR MO DAY <br /> LOCAT-TON FROM I . L TO <br /> (20-2/) (22.23 (24-25) (26- 7J (2 -29J (30-31/ NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION No. FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54-61) (38.4S) (46.53) (54.61) or <br /> (32.37) ! >< EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62.63 (64.68) (69.70) <br /> SAMPLE <br /> MEASUREMENT /J ( <br /> {.t`, �J<,. x.• .�.� l PERMIT i.,N h+'x''`+ /` ✓ +"'"�..y...Yr•ro=�Y. :,t •• . .,%,,4i �� z, ^�,'4ax. .;X4,S ,,, . ,i; "�, „s3£ `I�;'% % 's„4v-; <br /> • <br /> REQUIREMENT <br /> I"+w3 S,L T Y L�4 A�`i L-`. SAMPLE .. :,�a/,e ! •� v {'i Y'.' <br /> MEASUREMENT !r-� <br /> `r:• .1, -PERMIT = `.4w,,`apl.✓ '+� t.%•:si`'.i^' e• :t - y. ' ', •w"r '' ''"k ,;. o3RrY,,', 'y;•; ,. ,,°,b; •'r- �•.{; ��I,,L�j},., ✓tid4,,,w",�"y-5%%% <br /> REQUIREMENT t y �. a, %6':;r• 4. <br /> 1 ' - r4 t{�•I`` •;J % i T _ - r' • . .,' ,aI .r,,s "$ryyk ..ro„ <br /> a. }•.r Y t.r a .z I•.:J'...11= SAMPLE ' -I- <br /> 4 i- i••a:+ <br /> „ MEASUREMENT <br /> RMIT a :i:.. ..l..:y. 7Y^ +Y +,�, a� •;+ - ) `ss" �"r'a,'': ;, •'144. �'y w) �' ,i �,�3 ' "r,�M• .liin,�r'w.*.��•;,';�x k�-t«•1 "� <br /> '' r REQU{IREMENT j --'—/ f '., +a�;. .:„y- '�'' n"' ;,: ;w „q „y ,4:,;,. .r'�:,•,.��; <br />,'i..i�A•s f ..>a tY 1.;y 1��.{ J. a w., SAMPLE •a' 7c-F 'r . ti°.• y <br /> �q ' MEASUREMENT - <br /> PERMIT i*, £✓i.s°:•au' rl«rra i 't..i�`h`It z, A' •> y�"$F =: - , ' 'Z'St ;xt �0 ' <br /> REQUIREMENT a,,.. 'In- lY',•Y'; � <br /> ,1 <br /> ,.:,.1.1}':Y•t ' �E t.s I r�L SAMPLE •. ;. . -� • s: . ' <br /> y I 1 t ,A l MEASUREMENT 1 �/ <br /> PERMIT ;;yk,y `F,r M.t;r :;„; ',t b: 7S" Y'a� £,L, •+�a=<Nx i e s 1. -a• ,+a,i d' i.. �j .!�I•�. <br /> REQUIREMENT <'y z •t"`Mr q; .r»,�»+^^,.n..,,,, ��' -'i: <br /> ; ;A 1~. ,,... Y4la E.1 ;>�'r SAMPLE r w.y.w-„ :y.,F:F=eG^_� •F - -t •r•>^ <br /> +,y MEASUREMENT <br />:l 1 a 4'J•,L, q �p <br />..`�•� 6Vv L'+ - PERMIT {w. , , M A 4;,Cj>,...;;•— <br /> '•Y1! ;r '+., e "r, ;,*1. <br /> j$" ���.,. ,r•,')+5 �{ I REQUIREMENTIFa e LY pn •. ,sir 2'a•`"F°. �.;�y s ✓2:;•; „ i,,.�:s,,, "%'* <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' ' ., `• ,'6"e„ ,. ,a',,, <br /> REQUIREMENT ''„",'•4�: a f„ "r' ;5,%/., ,•�" <br /> t , <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 CERTIFY UNDIR PENALTY OF LAW THAT I HAVE PERSONALLY Exw MIN CD TELEPHONE D A T E <br /> AO AM FAMILIAR WITH THE INFORMATION SUBMITTED HERKIN AND pASKD 1 <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR 1 +� <br /> 1Y t ^F+�� 4.II"•L OBTAINING THE INFORMATION, I BELIE VB THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURA TK AND COMFLKTK. 1 AM ^WAR!THAT THKRK ARK SIG- j '2f9�bA t) ���,'-I�-.•� riV'-wl- <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING LVVL� 7 <br /> r��/t•� ) j THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE IS U.S.C. § I001 AND <br /> I I" '"�•Nj as U.s.c. § ISIY. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> (penalties under these statutes may include fines up to$10,000 <br /> TYPED OR PRINTED and/or maximum imprisonment of between 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT AREA I CODE NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> IS <br /> .v f <br /> - .. u.l. R'1 fl..r' ..� 4J� .0 A . ` !' S u • - t -- Y •'e 9 e - L - <br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (RCPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> UNTIL SUPPLY IS EXHAUSTED. - <br />