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PERMITTEE NAMF DDRESS (Include NATIONAL.POLLUTP DISCHARGE ELIMINATION SYSTEM(NPDL'SJ Form Approved <br /> FacilityName/Locat Iffere(it) DISCHAF AONITORING REPORT (DMRJ )MB No.2040-0004 <br /> NAME— /'� _ 1 �!_! _-----__ 12_. 17-19 Approval expires9-30-85 <br /> L,'� �_�: �_------__--- PERMIT NUMBER DISCHARGE N UMBER <br /> ----------- MONITORING PERIOD <br /> PACE LITY—� I I I YEAR MO DAV YEAR MID DAV <br /> LOCATION ' 1 r_I FROM TO , <br /> (20-21) (22-23J (24.25J (26.27) (28.29) 130=311 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) (38-45 46-53 No. FREQUENCY SAMPLE <br /> I (32.37/ j ) I ) (54-61) OF <br /> ( EX ANALYSIS TYPE <br /> j j I AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69.70) <br /> t r SAMPLE <br /> MEASUREMENT <br /> PERMIT fl . , v i ,I.i.,, ."•"v�+,} ✓? 4,,, .a <br /> REQUIREMENT <br /> SAMPLE <br />• MEASUREMENT ' <br /> PERMIT .... vn �,' .z,�'b` r 'r ,�«'rr.+>'xa•a .",.,,. <br /> REQUIREMENT <br /> p4 i - <br /> I, SAMPLE + <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> 'L <br /> • }I > r i. SAMPLE .� <br /> 1 1 MEASUREMENT <br /> PERMIT <br /> - r,• ° REQUIREMENT , <br /> - <br /> - SAMPLE <br /> MEASUREMENT <br /> .. PERMIT _ ., w �*y •i r e I - „.,� % c-F .e ^ <br /> a - i_. REQUIREMENT ' <br /> SAMPLE , <br /> MEASUREMENT <br /> PERMIT Mn z,-S• q'.,, ,r + , 't ` i„ T� �.:' , <br /> REQUIREMENT <br /> 4 , <br /> t_ • F _.... SAMPLE <br /> MEASUREMENT <br /> PERMIT " s r• yJ,, u ♦<.,-4 s+,.,� .. .'x < ;� .,, ,Y :`t:«fit <br /> ? . - REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I NAVE PERSONALLY EXAMINED 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 /> OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION _ - <br /> 1■ TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG- , <br /> NIFICANT ►ENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING - <br /> „ THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1e U.S.C. § I-f AND 1 _ S] U.S.C. § 1319. (penalties under these statutes may include fines up to$10,000 SIGNATURE OF PRINCIPAL EXECUTIVE <br /> TYPED OR PRINTED and/or maximum imprisonment ofbetween 6 months and 5 years) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO 13E USCD (F LPLAC S EI-A 1 ORM T-10 ::INCH MAY NOT BE UBCD.) AGC <br /> UNTIL SUPPLY IS EXHAUSTED. <br />