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P[RMITTlE NAMEIADORECS (Inrludr <br />Peediry Nrmr/LocElbn If diffnrnrl <br />IIAM[---=------== ----- <br />ADDIt[all :_ ~ ___________ __ <br />-- ~ ,~1.---------------- <br />-wnurr ____ <br />LOCATION ________________ <br />L <br />NnTIONAL FOLLU TA NT OIICNARGE ELIMINATION >1VSTCM (NPUE.SJ <br />DISCHARGE MONITORING REPORT /DMRI <br />zle /~ Form Approved. <br />• OMB'No.2040-0004. <br />PERMIT NUMelR RI:CNApGE N„M.ER - ~ Approval expires 6-30-91. <br />MONITORING PERIOD ~ r - - ~ Y <br />YEAR MO DAY YEAR MO OAY - _ ~'~ <br />FROM 1 l TO _ '. .. ' <br />I]n.nl Izzzal asasl nn.nl nx.za Im.ill NOTE: Read instructions before completing this form. <br /> (3 Card Only) qU ANTITY OR LOADING (4 Card Only) OU ALITY OR CONCENTRATION Fp EOU ENCV SAMPLE <br />PARAMETER (16-J3) (Jr6l) (fR~J) (16Ji) (JI61) NO <br />E% of <br />TYPE <br />(31-37) ANALYSIS <br /> AVERAGE MA%IMUM UHITB MINIMUM AVERAGE MAXIMUM UNITS <br />6161) <br />(6r6C1 <br />(69J0) <br />I SAMPLE <br />MEASUREMENT .. .. 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(. s R <br />~ ;fi.'S v :<, <br />.3 A• p _. ~ <br />9 <br />g <br />a <br /> SAMPLE <br /> MEASUREMENT <br /> Po <br />p , <br />~ a <br />° <br />~ <br /> 'REOUIREM &H T< " <br />x <br />_ r?. .p `° <br /> <br />a ' ` °Pe <br />n¢ <br />s "®' <br />sa <br /> <br />o- ( <br />n <br />s <br />'0 <br /> p e as <br />w .~p <br />> <br />y •x ~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l C[RTBr <br />unOER PENALTY OF uw TNAT I <br />NAV[ PERSONALLr [XAMw[O <br />ANO AM FAMILIAR WITH TNC INFORMATON SUBMITTED NEREIN <br />AHD BASED <br />~ TELEPHONE D A T E <br /> . <br />ON MY INQUIRY OF TNDrE INDVIDUALS IMNEDIATELV pE5PON51BLC FOR r <br />' <br />i;:~hard IV1lIIrj OBTAINING THE INFORMATIONY I BELIEVE THE SUBMITTED INFORMATION <br />5 TRUC ACCURATE AND COMPLETE I pM AWARE TNAT TNERE ARC SIG .' ;r <br />~I <br />~ ~~ <br /> NrFICANT PENALTIES FOR SVBMITTING FALSE INFORM1ipN INCLUpNG ~ / <br /> <br />~;i~~-o-;dental .11a ITIr~Fr' <br />THE POSSIBRrtr OF FINE AND IMPR50NNENT SEE IB USC f IOpI AND ( y <br />~/ U (~ <br />~/ <br />-6 (~•'1 <br />~ -T <br />~` <br />,II~ <br /> ]] uSC f 1319 rPrnrlpr, u.drr IArxr aamrr. nav nrludr pnr. uY e. ll4MVr SIGNATURE OF PRINCIPAL EXECUTIVE ` ` <br />' <br />TYPED OR PRINTED o•ul ~i. maammni mrpn.nnmvnl n/ArmrrnAmrmlA. and .5 •rar.r OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAT <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS lReJrrrnrr ull ulluellmenl] here) <br />EPA Form X2(}1 (Rev.9-88)PrevloD9 editions may lle USBd. 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