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PERMITI!gE NAME/ADDRESS(InClUde NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> ,fjUilityNe e/Loeationijdijjerent) DISCHARGE MONITORING REPORT (DMR) <br /> �< ------------- ----- 2.16 17.19 <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ------- ----- MONITORING PERIOD <br /> /AGILITY YEAR MO DAY I YEAR MO DAY <br /> LOCATION FROM TO <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. FREQOUF NCY 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 w m n ;s <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> -REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PEfiM iT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 3ZEQLI I�2£MENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REpEl•iptEMEENT <br /> SAMPLE <br /> MEASUREMENT <br /> #+��ibtlT <br /> t2�Qi.ttI�EMEIV3' <br /> SAMPLE <br /> MEASUREMENT <br /> Pt,�RMIT , <br /> tkR�IUIREMEN't' <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 I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> NIRCANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC S 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 US S 1319 tPenalnes under thew statutes may enrlude f,." up to slo.ww <br /> TYPED OR PRINTED .,ad or manmum Impnsonmrnt u1 hetu,een 6 month,and.i vear,t 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.9-88) Previous editions maybe used, (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />