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P��TE£ NA"'/ADDRESS (Include NATIONAL POLLUTAt ISCHARGE ELIMINATION SYSTEM (NPDLS) Form Approved <br /> :ncdrty Name/I.( v if dtperent) DISCHAR( ONITORING REPORT (DMR) MB No. 2000-0015 <br /> ADDRESS— t'f t I�Wit <br /> 1( r' IY <br /> ---- {• e'I t({< i'`1i•i IR S PERMIT NUMBER DISCHARGE NUMBER <br /> ---- ;- —————————————— MONITORING PERIOD <br /> -- -----_ YEAR MO DAY I I YEAR MO DAY <br /> LOCATION — FROM +,�. t• ! TO I ;�It, <br /> (.10-2)) (21 21) (24.2s) 1`1e-27i (28•29) (10-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-15) (46-53) (54.61) NO• FREQQUFNCY SAMPLE <br /> (31-37) :>< EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (62�3) (64fi8) ( YPE <br /> SAMPLE <br /> MEASUREMENT <br /> l I, c>�^ ( } F l l Ut t+ 1 ) ♦ r a a r <br /> PERMIT <br /> REQUIREMENT 1 a <br /> )` + a • a + z t 1 <br /> SAMPLE i <br /> f MEASUREMENT <br /> PIERM IT <br /> REQUIREMENT ! <br /> ♦ <br /> SAMPLE <br /> MEASUREMENT <br /> l nf,'�v0 � ibl /l� I <br /> PERMIT <br /> REQUIREMENT ; r <br /> r / <br /> SAMPLE <br /> MEASUREMENT ; l <br /> PERMIT <br /> .REQUIREMENT r / r <br /> SAMPLE <br /> MEASUREMENT <br /> {ill. +. <<:�1 �• iF 1 <br /> f ;;i;f ( PERMIT <br /> Y R100UIRHM9NT <br /> xIr. Aa f J / <br /> SAMPLE ` <br /> MEASUREMENT \� <br /> 1 !I E [';T ) PERMIT <br /> 7 REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <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 FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN, AND BASED <br /> I 'tW j1tz ��� ON MY INOUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INF N ORMATIO <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG- <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING / <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 1 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE 1 /� <br /> 33 USC 41319 (Penalties under these statutes may include fines up to $10.000 - <br /> TYPED OR PRINTED and/or maxim um Imprison mint of hetu•cen 6 months and•i years) OFFICER OR AUTHORIZED AGENT �-CIQDE <br /> A NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> i . � 1{ (`. I `:(.I(tet'!}� i;`-(' ,z ,.�:. j ' • ) r . ' t I .y :'t?' i " ., , le ) ,f I <br /> . I�r' ,"e. u1t(- Ttw' p ! 'r .; �" - - - s1 1 � I , s i' ,•t + ; F , , I <br /> PA Form 3320-1 (Rev, 10-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE or, <br /> UNTIL SUPPLY IS EXHAUSTED <br />