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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 <br /> PERMIT �<°,'a n . ., u w . ✓, w o,4 y"F ?>•s, ;; .+ <br /> •_ _-,t, ( S. l is it f. REQUIREMENT ��� , <br /> 77 ` <br /> SAMPLE !".> <br /> °• :1�• y MEASUREMENT <br /> PERMIT `: > y.,`�..-' .I. - af" - - •%'yw.a;x,*4.-,s.' ,s ;,v: •+,a ... f'«o 7 <br /> r-. REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ,. PERMIT . n.h.,. n mo a. 'y r ya.iy,K•;;�-'v^�;. g,:".*'"",¢*+, fi w .,, .c ,.»,., �. r, <br /> REQUIREMENT <br /> S i <br /> - SAMPLE _ <br /> MEASUREMENT <br /> -- .. PERMIT b 7 i°z" ,�»-_ , %'' '$;zG ri`°L „� .t., .. , , <br /> f V. REQUr#tEME'T <br /> SAMPLE <br /> ; - MEASUREMENT <br /> '- PERMIT <br /> 7 ... *. .; d ,i ,., . J,% -' u , *I, f'•,,, � ,`'� •r,°w,t." y <br /> REQUIREMENT <br /> t , <br /> ' SAMPLE <br /> Y ; ;1 MEASUREMENT ' <br /> PERMIT ;' a •w:s , .,i. M'!,K;?c• f' r,!6 r,; � t , 7 +"{' ;.* <'('% ,., :r,'t•'" <br /> REQUIREMENT ,t�;•'";,6e '� s <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT f n,.t. „l 4 <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 <br />