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iL' •;.r.T i kL •,: h; .. ,•+ c r.' lNPD: S <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER : rdA I is L3 i AN <br />FACILITY MONITORING PERIOD -T/ <br />LOCATION YEAR MO OAY YEAR MO DAY <br />FROM TO X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT C. <br />r REQUIREMENT ;•t 1rJTH <br /> SAMPLE <br />i„i= MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ;Ty <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT `, jA'! <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />r. REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT tQ OI'!T?lei .: ._. <br />} r I REQUIREMENT GL! : l <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - -r _ . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT REFOR'T <br /> REQUIREMENT F?TF? AVC <br />NAME,TITLE PRINCIPAL EXECUTIVE OFFICER I cemt under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under my direction or supen uion in accordance with a system destgne,! <br /> <br />" to assure that qualified personnel properly gudxr anti c%ahcue the mkxmaurnt / - _ <br /> submitted. Haled on my inquiry of the perscm or person% who manage the <br /> or those persons direc8 <br />responsible for gathering the information, the intormau.?r /L/ . <br /> y <br />suhnuti-M n,, to the best of my know ledge and belief, [rue. accurate, and enmpletr <br />I m <br />?s <br />r <br />that there ar <br />s <br />nif <br />ca <br />t <br />fo <br />m <br />f <br />i <br />t <br />f <br />b <br />l <br />f <br />SIGNATURE OF PRINCIPAL EXECUTIVE . <br /> <br />TYPE OR PRINTED a <br />a <br />e <br />ig <br />pena <br />or cu <br />mm <br />ig <br />orma <br />mn. <br />e <br />i <br />n <br />es <br />a <br />se <br />n <br />nxls Jmg rfx possnbnhty of line and tmpnxmment for tm,w mg sialuuons OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />... '.,w v?r r+?,.?r.v,• ve ?r? i •rvu+r rvn.a tnmere - an auou nmm?a rrera/ <br />AR REC I F E?IFNT - f= FE <br />EPA Form 3320-1 (Rev. 3M) Previous editions may be used. IUS ' -,? R. form. <br />j.SL