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PERMITTJE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/Locationifdijjerent) DISCHARGE MONITORING REPORT (DMR) <br /> — 2-16 17-19 <br /> ADDRUSS <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ------- `------- ----- MONITORING PERIOD <br /> FACILITY <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 FREQUENCY PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) NO. SAMPLE <br /> OF <br /> (32-37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63) (64-68) (69-70) <br /> r SAMPLE <br /> MEASUREMENT <br /> r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> a.....�..-. <br /> - - -REQUIREMENT . <br /> r SAMPLE - - <br /> MEASUREMENT <br /> PERMIT I s <br /> REQUIREMENT <br /> r SAMPLE - � <br /> MEASUREMENT rrtt v <br /> i' � <br /> PERMIT - , - � • ''" .,,>: -{- '' tf <br /> I3EttU ER£MLNT, 1 �� <br /> r <br /> SAMPLE r _ <br /> MEASUREMENT <br /> PERMIT <br /> R�QEEI1tRMEN�' �. <br /> r SAMPLE <br /> MEASUREMENT <br /> REQUIIi1E:EA8NT - ' < <br /> r SAMPLE <br /> r MEASUREMENT <br /> ELEIq(;i)REMEN'} Y i v <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 Jt <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR r r <br /> ��j�',r1.� J,f frr':� -•' -r OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG �� 1��+•' _ <br /> i NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING f'^ <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IB USC 4 1001 AND <br /> t, SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 US 41319 tPe—lt— under thew statute, may -elude f~., up I,, Elo(N)I) } t <br /> TYPED OR PRINTED —d ,,---mlpr.,an m.nt o/hvtuvwn 6 month,and.i war,) OFFICER OR AUTHORIZED AGENT AR A NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> . x r <br /> EPA Form 3320-1 (Rev.9-88) PreVlous editions maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />