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PERMITTEE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/Location tf different) DISCHARGE MONITORING REPORT(DMR) <br /> NAME__ ____ ___ ___ ___ (2-16) (17-19) <br /> ADDRESS _____ _ __ _ ____ _ _ <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> FACILITY MONITORING PERIOD <br /> ———— — —— —— -- ———— —— --LOCATION FROM YEAR MO DAY TO YEAR MO I DAY <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 NO FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) EX OF TYPE <br /> (3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> (62-63) (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PE"tT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE DATE <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- <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 US C § 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 U S C § 1319 (Penalties under these statutes may include fines up to $10,000 AREA <br /> TYPED OR PRINTED and ormarimumimpnsonmentof between 6 months and 5years.) OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS(Reference all attachments here) <br /> EPA Form 3320-1(Rev.9-88)Previous editions maybe used. (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) PAGE OF <br />