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PERMITTEE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Nome/Aocationijdijjerent) DISCHARGE MONITORING REPORT (DMR) <br /> MAIMS-------------+----- 2-16 17.19 <br /> ADDRESi <br /> -------------------- <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> -------=----- — ---- MONITORING PERIOD <br /> rwu uTtir <br /> -------^------- --- YEAR MO DAY I YEAR MO DAY <br /> LOCATION FROM TO <br /> -------------------- <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 y, <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) NO. FREQOUFNCY SAMPLE <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 /> PERMIT r ?■ t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .., .. IxEftlM[I1. <br /> REQUIREMENT <br /> • s <� t r I •r x. <br /> SAMPLE <br /> MEASUREMENT <br /> REQUIREMENT <br /> SAMPLE .6 <br /> MEASUREMENT <br /> r <br /> PERMIT ::f"%,,>,' .F •• ^'r,. ,. . - ^ y{ 4 <br /> SAMPLE I 1`- <br /> MEASUREMENT <br /> PERMIT R r• `� g. > , f P. <br /> R>:pE)1IlEMtwNT <br /> SAMPLE <br /> I MEASUREMENT <br /> �lEQi1I1ZP�eEE1�'I' <br /> r .,. r <br /> r SAMPLE <br /> MEASUREMENT <br /> M�yPERMIT Y � � `k :�,.$ `% �` .+ . `> $" ,b. v:', ,i r � � 1• <br /> lLIEiCItI IREM EN'C <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 /> - / ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAIN THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION <br /> 15 TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> ING <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING ` �• .�-/- <br /> /;' THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC § 1001 AND f :rF- j `�r �r -•>�Y 33 U S C §1319 /Penalties under thew statutes may include fines up to $lu tNtli SIGNATURE OF PRINCXPAL EXECUTIVE <br /> TYPED OR PRINTED ur I or maximum imprisonment o/hetmeen 6 month.,and 5,ean i OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> — r w <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 />