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<br />NAME U
<br />ADDRESS C
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />,
<br />Form A-
<br />- OVed.
<br />DISCHAR ONITORING REPORT (DMR),
<br />(2-1 17-191
<br />,• ' 1
<br />'
<br />SAMPLE
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<br />l rI �
<br />(38-45 (46-53) (5461)
<br />EX
<br />r. '> I
<br />Apprrol
<br />pieso 05 31-98
<br />MAXIMUM
<br />PERMIT NUMBER
<br />MINIMUM
<br />DISCHARGE NUMBER
<br />MAXIMUM
<br />UNITS
<br />162-631
<br />AN(6464-66)
<br />8)
<br />MONITORING PERIOD
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<br />SAMPLE
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<br />YEAR MO DAY
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<br />120-21) 122-23) (24-25)
<br />126-271
<br />128-291 13&311
<br />NOTE: Read Instructions before Completing this form.
<br />PARAMETER
<br />,
<br />(3 Cord Only) QUANTITY OR LOADING
<br />(4 Card Only/ QUANTITY OR CONCENTRATION
<br />NO•
<br />FREQUENCY
<br />SAMPLE
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<br />(38-45 (46-53) (5461)
<br />EX
<br />OF
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />MINIMUM
<br />AVERAGE
<br />MAXIMUM
<br />UNITS
<br />162-631
<br />AN(6464-66)
<br />8)
<br />TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON
<br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTAINING THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION IS
<br />'
<br />�-
<br />TELEPHONE
<br />DATE
<br />F,: 1
<br />TRUE, ACCURATE AND COMPLETE. 1 AM AWARE THAT THERE ARE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />- i '`r%i5 !'-f%✓',
<br />SIGNATURE OF PRINCIPAL/ XECUTIVE
<br />OFFICER OR
<br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 1 1001 AND 33
<br />U.S.C. 1 1318. Iftn.Mss under twat statutes may lncluds dines &V to $ 10,000
<br />end ormaxmwnkr
<br />TYPED OR PRINTED
<br />AREA NUMBER
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<br />AUTHORIZED AGENT
<br />CODE
<br />YEAR
<br />MO
<br />DAY
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<br />RP PPI•Tc:C T) o:i), tPr':D ".r.A iU' -C
<br />EPA' dorm `33 0=1 (08-95) Previous editions'm;y be used. 0
<br />(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)
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