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PERMITTEE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility XanWLacationijdtjjerent) DISCHARGE MONITORING REPORT(DMR) <br /> -- — r----- — 2-16 17.19 <br /> ADD R IES$ <br /> ' PERMIT NUMBER DISCHARGE NUMBER <br /> -------- -------- --- MONITORING PERIOD <br /> ►AGILITY YEAR MO DAY I YEAR MO DAY <br /> -------------------- <br /> LOCATION FROM TO <br /> (20-21) (22-23) (24-25) (26-27f (28-29) (30-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION s, NO. FREQUENCY SAMPLE <br /> PARAMETER (46-53) (5461) (38�5) (46-53) (3461) OF <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 <br /> REQUIREMENT <br /> r SAMPLE <br /> MEASUREMENT <br /> T F.Er�tellT wawe.w,+*..w., - -ww...�. .«... ..........v .tw,e..r`7';c±'t.;°' - ' 'xf','�,•f'+,- 'M - -sl r.-s?+'ye.�SbR -eV$M-•aas? <br /> _ PkEQulia£MEfaIT <br /> SAMPLE -- <br /> r MEASUREMENT <br /> PERMIT <br /> r SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> Reau t R£M914T <br /> SAMPLE <br /> MEASUREMENT 1• <br /> ( <br /> RE6iE#IIMtEMEN'Y' <br /> / SAMPLE <br /> t 1 MEASUREMENT <br /> (;t�QLI EYiEkt�#V7' <br /> ^.ems �- r .� s •r <br /> r SAMPLE <br /> MEASUREMENT <br /> PERMIT o <br /> I't(};I�UIIpEb1ENT' <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 /> OBTAINING THE INFORMATION 1 BELIEVE THE SUBMITTED INFORMATION ,J! <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG —�[i. '`("Ter+ _,--n' Lr. <br /> ! NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> ! C THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 U S C 4 1001 AND p" I ^'��• I`�r/ / <br /> 3 USC 11319 /PenaIt—, ..d,, thew states may -rl 1�nY• up tea .f/fl fNNI ude SIGNATURE OF PRINCIPAL EXECUTIVE �` -3 �✓:"• '�+ ��_.i{lj �_i <br /> TYPED OR PRINTED nau 3 l or ma s�mum rmpn,+amm�d u(hetuwn 6 moutnth+and 5 wan I OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (Rev.948) Previous editions maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />