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PERMITTV NAME/ADDRESS(InCl4de NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility,Ng)kAjacatbnijdijjerent) DISCHARGE MONITORING REPORT IDMRI <br /> -- _ _�-- 2-16) (17-122 Form Approved <br /> ADDREsss�_--_--`--__----`— OMB No. 2040-0004 <br /> PERMIT NUMBER DISCHARGE NVMBER <br /> ---------�---.--L—_—._�_---_— - Expires 9-30-91 <br /> ----- MONITORING PERIOD <br /> rwcrury <br /> '--�-----'--^�------------- YEAR MO DAY YEAR MO DAY _ <br /> LOCATION FROM TO <br /> (20-21) (22-23) (24-25) (26-27) (28-29) (30-3/J NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) OF TYPE <br /> EX ANALYSIS <br /> (32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> 62-63) (64-68) (69J0) <br /> SAMPLE <br /> MEASUREMENT <br /> AeOUIREM ENT <br /> SAMPLE <br /> MEASUREMENT <br /> ...... .v,,.. ....-.. <br /> PIwF#M#r' <br /> RRQUIRE#A 6N'f` <br /> SAMPLE <br /> MEASUREMENTVV <br /> - <br /> PERMIT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT k � « •• <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> IRE*UIRIE M ZNT <br /> SAMPLE <br /> MEASUREMENT <br /> PERM IT <br /> R£QUIREM'ENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERM IT <br /> REa#,IREAlICNr` <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 SUBMITTED HEREIN AND BASED <br /> J ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> r f"\,' '}�/' '� f OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION - <br /> "' IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG f �,/�.,r `• r r ,%% y \ <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> - �'•✓ THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 16 USC 4 1001 AND <br /> ---- 33 USC 41319 tPvnah— under thew Uat.t— may —Id,(Inv. uP to $/unon SIGNATURE OF PRINCIPAL EXECUTIVE <br /> TYPED OR PRINTED and„r maximum mlpr—jar —nt o/hM•mwvn 6 month,and 5 want OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> r <br /> f ` <br /> EPA Form 3320.1 (Rev.9-88) Previous editions maybe Used. IREPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />