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PERM IT`VEE,NAM E/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/Locationifdijjerent) DISCHARGE MONITORING REPORT(DMR) <br /> �-titer-------------+----- 2.16 17-19 <br /> ADDRC" <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ---" --`"}L----- ------ MONITORING PERIOD <br /> FACILITY <br /> --------------------- YEAR MO DAY 1 YEAR MO DAY <br /> LOCATION FROM TO ' <br /> -------------------- <br /> (20-21) (22-23) (24-25) (26.27) (28-29/ NOTE: Reed 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. FREQUF NCY SAMPLE <br /> O <br /> (32-37) E% ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS>< 62-63) (64b8) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> -- <br /> t ., . }.. .. .I .� RTYEI'1• ,t,.1N,..,.I...,t..xt.gk. ,.x kG nos-r* ..:� ,< .f-3C-#�t?E�R- - 4A -- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> tSAMPLEt <br /> MEASUREMENT <br /> PERMIT J� <br /> iR8CTi3 eit£M£N'C <br /> r SAMPLE I •~ <br /> MEASUREMENT <br /> RLCiEJITtEMeeiNi � .. F <br /> SAMPLE <br /> f s MEASUREMENT <br /> SAMPLE <br /> "MEASUREMENT <br /> P€RMIT t <br /> ttE+CtUIR MEN'T . <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY+OF LAW THAT 1 HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> / 1 ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION 1 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 (f ^✓ \ �� } �/ <br /> f cam',�� J THE POSSIBILITY OF FINE AND IMPRISONMENT SEE IB USC 4 1001 AND <br /> 33 US 41319 (Penalties under thew statutes may include fines up h, $101Iimf SIGNATURE OF PRINCIPAL EXECUTIVE �./ _d <br /> TYPED ORPRINTED o,Id or mas rn Impsu,n meat of hetmeen 6 months and 5 years I OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference till attachments here) I CODE <br /> EPA Form 3320.1 (Rev.948) Previous editions maybe Used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />