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PERMITTEE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES)Facility L w <br /> Name/Location ijdrjjerent) --- ——— ——— DISCHARGE MONITORING REPORT(DMR- ,1�1�,G <br /> NAME__ ____ —— — — (2-16) (1719) (,1 � /I��� <br /> ADDRESS _____ _ __ _ __ t.�, <br /> PERMIT NUMBER DISCHARGE NUMBER ' <br /> FACILITY __ _ __ __ ____ __ YEAR MO O DAYORIN 1 y RIODMO 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. FREQUENCY SAMPLE <br /> EX OF TYPE <br /> (3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> (62-63) (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE DATE <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 /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 US C § 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 U S C § 1319 (Penalties under these statutes may include fines up to $10,000 <br /> TYPED OR PRINTED andormaximum imprisonment ojbetween6monthsandSyears.) OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS(Reference all attachments here) <br /> EPA Form 3320-1(Rev.9M)Previous editions maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />