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'ERMITTEE NAM DRESS (Include NATIONAL POLLUTA' ISCHARGE ELIMINATION SYSTEM(AIPDES) orm Approved
<br />"acilityName/Locati ferent) ; DISCHAR ONITORING REPORT(DMR) MB No.2040-0004
<br /> V AM E_ " k 1 ' I - - 2-1 17.19 Approval expires 9-30-85
<br />---------------------
<br /> .. ...•tlJ/•I � , i PERMIT NUMBER DISCHARGE NUMBER
<br /> ---------- MONITORING PERIOD
<br /> FACILITY-- I �_?_------------ YEAR MO DAY YEAR MO DAY
<br /> LOCATION FROM TO
<br /> (20-21) (22-23J (24.2SJ (26.27/ (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 46-53 NO. FREQUENCY SAMPLE
<br /> ( ) (54-61) (38-45) (46-53) (54-61) OF
<br /> (32.37) 4 � EX ANALYSIS TYPE
<br /> I AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70)
<br /> 1 { S t ! SAMPLE '
<br /> MEASUREMENT ,
<br /> P14 MIT
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 CERTIFY UNDER PBNw LTv OF LAW THAT 1 HAVE PERSONALLY EAw Min ED 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, 1 BELIEVE THE SUBMITTED INFORMATION
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG-
<br /> _ NWICANT PENALTIES FOR SUBMITTING FALSE INFORMATION. INCLUDING '
<br /> 1 THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE IS U.S.C. § 100S AND SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> SS u.s.c. g /ols. (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTgD and/or maximum imprison men t of between 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> EPA Form 3320-1 (Rev. 10-79) PREVIOUS EDITION TO OE USFD (REPLACLS CPA i O.:'A T AG 1J.SICH MAY NOT IL U CU.) Pf,C OF
<br /> UNTIL SUPPLY IS EXHAUSTED.
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