Laserfiche WebLink
PERMI7TEE NAME/ADDRESS(Incl4de NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> _,FacilityNarW/Locationijdtjjerent) DISCHARGE MONITORING REPORT (DMR) <br /> -- =---------'----- 2-16 17.19 <br /> AdDRE:f - <br /> ' PERMIT NUMBER DISCHARGE NUMBER <br /> -------------- ----- MONITORING PERIOD <br /> IrACI LITY <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 <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) NO, FREQOUFENCY SAMPLE <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 /> PERMIT <br /> ,REQUIREMENT . . K <br /> SAMPLE <br /> MEASUREMENT <br /> 4..4 « PLAurri- <br /> - - REQUIREMHIVT � :r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT � <br /> REQUIREMENT <br /> 1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQLiIitSMENT <br /> SAMPLE / <br /> MEASUREMENT <br /> PERMIT <br /> R9*t$jRIKMENT <br /> SAMPLE <br /> MEASUREMENT <br /> REQVI��tetEIVT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> RV41IJ1IRRMENT <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 /> 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 •CL.r rat"`1`,�+' ���j r`=v ' S <br /> r NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> / THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 U S C 4 1001 AND <br /> 33 U 5 C S 1319 rPenaltees under Ihese statutev nrnv include fat— up to EI0(KN) SIGNATURE OF PRINCIPAL EXECUTIVE -t •-� - - 1 <br /> TYPED OR PRINTED and or maximum rmprlsonmrrnf o/hetu—n 6 month,and 5 wan r OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> r <br /> • • r r a <br /> EPA Form 3320-1 (Rev.9-8S) Previous editions maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.( PAGE OF <br />