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ERMITTEE NAME1 ODRESS (Include NATIONAL POLLUTANT ISCHARGE ELIMINATION SYSTEM(NPDES) corm Approved
<br /> acaityNarre/Locati fere{It)`1 DISCHARI ONITORING REPORT (D.1IR) IMB No.2040-0004
<br /> AME °«� .� !a - ----------- 2-1 (17-19 Ipproval expires 9-30-85
<br /> PERMIT NUMBER olscHAR GE NUMBER
<br />---- �++ ! --- MONITORING PERIOD
<br />_AC 11,1 TY : i I ��--___--_------ YEAR MO DAY YEAR MO DAY
<br />.00ATION _T f 4 FROM TO _ -
<br /> = w` 74 i �:! y (20-21) (22.23J (24-25J (26.27/ /28-29) (30-31) NOTE: Read instructions before completing this form.
<br /> 1 i j 1 1 (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> FREQUENCY
<br /> PARAMETER I (46-53) (54-61) (38-45) (46-53J (54-61) No. OF SAMPLE
<br /> (32-37) 1 >< EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70)
<br /> f SAMPLE
<br /> I i MEASUREMENT
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<br /> REMENTREQUI
<br /> LAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY or LAW THAT I HAVE PERSONALLY [AAM1N[D TELEPHONE D A T E
<br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED '
<br /> + ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> + [ r OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION ,
<br /> 1■ TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE ■IG- '
<br /> NIPICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br /> THE POSSIBILITY OF PINE AND IMPRISONMENT. ■EE 1• U.S.C. § 1001 AND +
<br /> ' - -- 11 u.s.e. § 1115. (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 CODE AREAJ NUMBER YEAR MO DAY
<br /> OMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> PREVIOUS EDITION TO BE USED
<br />.PA Form 3320-1 (Rev. 10-79) UNTIL SUPPLY IS EXHAUSTED. (R CPLAC ES EPA FORM T-40 WHICH MAY NOT BE USCD f PAGE OF
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