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PE .TTEE NAME/ADDRESS{Include NATIONAL POLLUT T DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br />,FVF17itv Name/Loco dlf+fer tJ? DISCHA MONITORING REPORT(DMR)
<br /> OMB No.2040-0004
<br />±UlkM E-- ;:L�1' ' E�`>',.!. ti- - :_'. --- 17-19 )- _• ! i ��. Approve/expires 9-30-85
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<br /> \i (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION NO. FREQUENCY
<br /> PARAMETER +, (46-53) (54.61) (38-45) (46.53) (54-61) OF SAMPLE
<br /> I (�2-37J � •�,,.� EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE a MAXIMUM UNITS t i 62-63 (64-68) (69.70)
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<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 SU.MITTED HEREIN AND EASED I
<br /> ON MY INQUIRY OF THOSE INDIVIDVALS IMMEDIATELY NKSPONt1ELK FOR ' / /j
<br /> OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION J�� -}'1 ..J� `��-%t HIA
<br /> 15 TRUC, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARK SIG'
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<br /> NIPICANT PENAL. FOR EUH MITTINO FALSE INFORMATION,MATZOH, IN CLUOIND ,/t�1y� (� 6 �j
<br /> rHe Fos{IHI LITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. § lool AND SIGNATURE OF PRINCIPAL EXECUTIVE J -)3 1��� JV+�f/• 4'1
<br /> as u.s,c, g Is19. (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTED 1 and/or maximum imprisonment of between 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br /> CODE
<br /> COMMENTAND•(EXPLANATION f ..,{�S� 1 ;QFA+N,YVIOLATIIONS (Reference all attachments here) 1 `' �(
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<br /> EPA Form 3320-1'(Re'v.'117-79Y IR11 IOUS SUPPLYEDITION
<br /> IS EXHAUSTED.TOBEUSED
<br /> (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
<br /> UNTL1
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