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PERMITTEE NA- 1ADDRESS (Include NATIONAL POLLUT^•'T DISCHARGE ELIMINATION SYSTEM(NPDES) Form Approved
<br /> Facility Name/Loa different),., DISCHA MONITORING REPORT(DA1R)
<br /> NAME `' _ _ 17.19 OMB No.2040-0004
<br /> — ------------- Approval expires 9-30-85
<br /> ADDRESS
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<br /> Ij. {'•j' PERMIT NUMBER DISCHARGE NUMBER
<br /> _-----------
<br />'-----'---+--^----------- MONITORING PERIOD_
<br /> M'ACI LITY i I ( i — —• —•
<br /> YEAR MO DAY YEAR MO
<br /> DAY
<br /> LOCATION � ( I ! ^--_--•_--_—__--- FROM
<br /> s.�!v `• 1•'s ., r (20-21 (22.23) (24.25) (26.2 ) (28.29) (30-31) NOTE: Read instructions before completing this form.
<br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> PARAMETER I I (46-53J (54.61J (38-45 46-53 FREQUENCY
<br /> J ( ) (54-61) NO. OF SAMPLE
<br /> (?2-3,7) 1 i . EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>—< 62-63 (64-68) (69-70)
<br /> 1 + I SAMPLE
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<br /> REQUIREMENT .t ,
<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PHN.LTY OF I.- THAT I HAVE PERSONALLY ..AMINE. TELEPHONE D A T E
<br /> AND AM PAM ILIAR WITH THE INFORMATION SUBMITTED HKREIN AND SASKD
<br /> I f ON MY INQUIRY OF THOSE INDIVIDVALS IMMEDIATELY RESPONSIBLE FOR '
<br /> OBTAINING THE INFORMATION, I BELIE VK THE SUBMITTED INFORMATION
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARK SIG-
<br /> NIFICANT PKNALTIKS FOR SUBMITTING FALSE INPORMATION, INCLUDING
<br /> THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE Is U.S.C. I tool AND SIGNATWi'E OF PRINCIPAL EXECUTIVE
<br /> 93 U.S.0• g 1319. (Penalties under these statutes may include fines up to$10,000 P
<br /> TYPED OR PRINTED and)or maximum imprison men t of between 6 nion th sand 5 years) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br /> CODE
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (R ejeren cc all attach men is here)
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<br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO BE USED (,i L7'LACLS EPA I"OitM T-40 1',i.ICH MAY NOT DE U CD.) P, GC
<br /> UNTIL SUPPLY IS EXHAUSTED.
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