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PERMITTEE NAME'ADDRESS (Include NATIONAL POLLUT--"T DISCHARGE ELIMINATION SYSTEM(NPDESI form Approved
<br /> FacilityName/Loc different) DISCHA MONITORING REPORT (DMR) OMB No.2040-0004
<br /> NAME
<br /> i 17.19 Approval expires 9-30-85
<br /> ADDRESS t
<br /> +, J r_ 4�..•1: PERMIT NUMBER DISCHARGE NUMBER
<br />-------r—;--�----------- MONITORING PERIOD
<br /> FACILITY-
<br /> -- --- — ------------- YEAR MO DAY YEAR MO DAV
<br /> LOCATION + FROM TO _
<br /> (20-21) (22.23) (24.25) (26.27) (28.29) (30.31) NOTE: Read instructions before completing this form.
<br /> 1 (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION
<br /> NO. FREQUENCY SAMPLE
<br /> PARAMETER 1 (46-53) (54-61) (38-45) (46-S3) (54-61) OF
<br /> (j2.37) ) EX ANALYSIS TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63 (64-68) (69-70)
<br /> i
<br /> SAMPLE
<br /> MEASUREMENT '+w
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<br /> REQUIREMENT
<br /> SAMPLE
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<br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY Or LAW THAT I HAVE PERSONALLY EXAMINED _ TELEPHONE D A T E
<br /> ANO AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
<br /> ON MY INQUIRY OF THOSE INDIVIOVAL■ IMMEDIATELY RESPONSIBLE FOR
<br /> - - OBTAINING THE INFORMATION, I BELIEVE THE ■UBMITTED INFORMATION '
<br /> IS TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIG- ,
<br /> • N.FICANT PENALTIEB FOR SUBMITTING FALSE INFORMATION, INCLUDING -
<br /> • THE POSSIBILITY Or FINE AND IMPRISONMENT. SEE IN U.B.C. 1 IUSI AND SIGNATURE OF PRINCIPAL EXECUTIVE '
<br /> as U.S.C, g ISIS. (Penalties under these statutes may include fines up to$10,000
<br /> TYPED OR PRINTED and/or maximum imprisonment ojbetween6months and SyearcJ OFFICER OR AUTHORIZED AGENT AREAJ
<br /> CODE NUMBER YEAR MO DAY
<br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br /> EPA Form 3320-1 (Rev. 10-79) UNTIL SUPPLY IS E TO BE USED
<br /> (REPLACES EPA FORM T-40 INHICi- MAY NOT CE USED.) PAGE: O:_
<br />
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