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PERMITTEjr,NAME/ADDRESS(IItCIttdC NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> F <br /> a <br /> ci <br /> l <br /> i <br /> t <br /> y <br /> Namti•/Locotionijdijjerent) DISCHARGE MONITORING REPORT (DMR) <br /> `-------------+----- 2.16 17.19 <br /> ADDRE>i! <br /> -------------------- <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> --- -- MONITORING PERIOD <br /> FACILITY <br /> --------^------------- YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM TO <br /> -------------------- <br /> (20-21) (22-23) (24-25) (26-27) (28-29) /30-3!) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION 5, <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (5461) ND, FREQOUFENCY SAMPLE <br /> TYPE <br /> (32-37) EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63) (6468) (69-70) <br /> SAMPLE r'~} <br /> MEASUREMENT /Z.. <br /> PERMIT <br /> •REQUIReme"T eSAMPLE <br /> r MEASUREMENT <br /> e. P&RUI7 w. At�.+tw n n *v. ..r , s_ ?.a«a a.w Po ea q e + _.sr s� R►, +P rid t tip <br /> REQUIREMENT i <br /> t SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> ,REQULREMENT , <br /> SAMPLE <br /> MEASUREMENT l�I <br /> PER <br /> RHQU lItEMENT, <br /> r SAMPLE 'I <br /> MEASUREMENT <br /> ✓y <br /> PERMIT <br /> RL+�EIIREMENT . <br /> t SAMPLE <br /> 1 MEASUREMENT <br /> PERMIT w; �.• - ". c / Y ` �`x, <br /> ROQUIREIe 04T <br /> r SAMPLE <br /> MEASUREMENT f �1/ �/ Z, , f j <br /> �r <br /> C- 'C <br /> _ PKRU IT < x' Y,.^,`'' •�!x. >�^ r a� , <br /> RE1lttiIR ENT :a L � <br /> 9 f <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED i7 TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> ) f r ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR ' <br /> „�j/•7(_ "1' I1"" rr(' r� OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> • / 7 <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG •� .' �'' <br /> t NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 4 1001 AND SIGNATURE OF PRI 'IPAL EXECUTIVE <br /> 33 US C 4 1 31 9 (Pvnalae, andvr thew smtatea maY In,lude/Inv,, up trl $10(X)a ' <br /> TYPED OR PRINTED alul or manmum mlpn uulmrnt u(hvtmrvn 6 month,and 5 war,t OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> r <br /> EPA Form 3320.1 (Rev.9$8) Previous editions maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) r PAGE OF <br />