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PERMITTEE NAM 7DRESS (Include NATIONAL POLLUT/ '71SCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Na tfferent) DISCHAR IONITORING REPORT (DMR) <br /> NAMlC— e +� * ------ ---- 2-, 17-19) -- <br /> A_D6REY>i,� bar ri •,t'r ,1 'i:� - - , <br /> -'1 A9;f1 '} �("; 1,1' FPERMIT NUMBER DISCHARGE NUM BER <br /> -- j--- {' 'T------------ MONITORING PERIOD <br /> lA'AC141TY ---- <br />—��---.�------------- YEAR MO DAY YEAR MO DAY <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 /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) NO. FREQUENCY SAMPLE <br /> OF <br /> (32-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (62-63) (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> e1 PERMIT a , <br /> -R.EQUIREMENT <br /> • - -'i SAMPLE <br /> MEASUREMENT <br /> PERM IT <br /> ' REQVIREMENI s, , <br /> SAMPLE <br /> MEASUREMENT I" - <br /> 3', s PERMIT ew, >^, <br /> .REQVIREMENT <br /> ' - •, SAMPLE - <br /> ;r MEASUREMENT <br /> PERMIT <br /> REQLiiREMENT :. <br /> 1.r' ':y •f,(�,r %,1, SAMPLE <br /> ,^y MEASUREMENT '—/, <br /> -I PERMIT <br /> t• t y• `�'r REQUITEMENT <br /> 7 7— <br /> SAMPLE <br /> MEASUREMENT <br /> PERM IT ; <br /> REQUIRQMENT <br /> SAMPLE - <br /> 'e MEASUREMENT <br /> PERMIT <br /> 1. REQUIREMENT <br /> a <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> {. ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG / r <br /> �— NIF ICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING ) - - <br /> "P ! �. °•-r-'I THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 4 1001 AND i 1 r <br /> 33USC 111319 t!'vnaltu� under thv.v stow- ma. ,n,ludr Jrnr., up a, $roona SIGNATURE OF PRINCIPAL EXECUTIVE ' <br /> TYPED OR PRINTED ara( ur masmlurn rmpnxrnm,,t„(hvtuvwn 6 munch.a d 5 v.a OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (Rev. 10-7.9) UNTIL SUPPLY IS E TO RE USED <br /> (I;CPLACES EPA roRM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />