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PERMITTEE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/Locationifdifferent) DISCHARGE MONITORING REPORT(DMR)M£----==-------J----- 2.16 17.19 <br /> ADDRtlf ' <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ---- —`— --- — --- MONITORING PERIOD <br /> Pwcl uT�r <br /> -------------- ----- YEAR MO DAY I I YEAR MO DAV <br /> LOCATION FROM TO <br /> (20-21) (22-23) (24-25) (26-27) (28-29 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. FREQOUFENCY SAMPLE <br /> (31-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 61-63) (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> -- - -- - - - - -- .REQUIREMENT <br /> r SAMPLE <br /> MEASUREMENT <br /> ... .+ ,, # iGIIT x/.�zxs ss s�+'s <sk�;fi;a s*,E eq.�.. .�°�,. a.n..uf..,rr..,*,.+t �..,c - - ^►_•. .. ,�,�.,..,....I.. y ,.y.-..^.,� <br /> .. ftiEgt31REMENT <br /> ? s r / 3 <br /> SAMPLE <br /> MEASUREMENT <br /> PEitIkA 171' •. ,, "-'•ske •• e i + ¢ t <br /> REQUIREMENT t k <br /> r SAMPLE \ - <br /> MEASUREMENT •� <br /> #2EQV E R£M£fI C y <br /> r SAMPLE <br /> MEASUREMENT `+ <br /> RLEI•EI1rtEM EN'E' <br /> 3 ? t <br /> SAMPLE <br /> t MEASUREMENT <br /> ,I:'fEQiiIREIKHNT ., . <br /> SAMPLE <br /> MEASUREMENT <br /> pERFd[T � - <br /> IItE�IU INtEM EN'� <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ` `' yc_I ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> - {-• *'L'' t t rk' �, ..-+• k OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION Air, <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 USC 4 1001 AND <br /> 33USC 41319 lPenaltier under the statutes may include fines up to SIU INIa SIGNATURE OF PRINCIPAL EXECUTIVE I <br /> TYPED OR PRINTED and ar ma—um Impnwnmvnt of twtu-een 6—nth,and.learn) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (Rev."8) Previous editions maybe Used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />