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PERMIT.NAME/ADDRESS(InCIUde NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> F Fdty,%rne/Locationifdlfferent) DISCHARGE MONITORING REPORT(DMR) <br /> ±rA --- ----- 2.16 17.19 <br /> ADDREss i <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ------- ------ MONITORING PERIOD <br /> FACILITY <br /> -------------------- YEAR MO DAV YEAR MO DAY <br /> LOCATION FROM TO ' <br /> (20-21) (22-23/ (24-25J (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 <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 /> eRM IT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> t'�'A+ MFNY A+.f.rrA.�M i-4 fit. V. yy <br /> L ti 'a <br /> SAMPLE r <br /> MEASUREMENT J <br /> PERMIT <br /> KSQLTlREME3�1'!' � ,r. <br /> SAMPLE <br /> MEASUREMENT <br /> i� <br /> PERMIT <br /> 14EQ13 E1t£M£FI'C, '` <br /> SAMPLE t <br /> MEASUREMENT <br /> PERMIT <br /> REp UI Kt EM EN*' <br /> SAMPLE <br /> MEASUREMENT <br /> DIEM It' <br /> I�liQu IIZEktHN'1' <br /> SAMPLE <br /> MEASUREMENT <br /> psRM1T <br /> #kE(?t#RWMEN'Y <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 /J <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR , <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION ,• <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG . le <br /> NT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> pf�• ._,+ <br /> NIFICA �l-!` y/ ( �..., <br /> THE POSSIBILITr OF FINE AND IMPRISONMENT SEE 18 USC 4 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE -\�-� f '. -,f'�t 7,"� <br /> 33 U S C 41319 (Penalties under thew statutes may include fines up it) $m(MM) <br /> TYPED OR PRINTED and ,,maximum imprisan men/a(hetu evn 6 month.and 5.ears OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) CODE <br /> • r s <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 /> r - . <br />