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PERMITTEE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Namel7Locattoo ifdifferent) DISCHARGE MONITORING REPORT(DMR) <br /> fu1E (2-16) (17-19) <br /> ADDRESS <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> -- —-- -- — — — ----- ---- MONITORING PERIOD <br /> FACILITY —— — —— —— _— ———— —— YEAR MO DAY 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. FREQUENCY SAMPLE <br /> >< OF <br /> (3237) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> (62-63) (64-68) (69-70) <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 /> 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 1 HAVE PERSONALLY EXAMINED TELEPHONE DATE <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN,AND BASED <br /> ON MY INQURY 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 § 1001 AND SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 33 USC § 1319 (Penalties under these statutes may include fines up to $IQ000 AREA <br /> TYPED OR PRINTED and or maximum imprisonment ofbetween6 months and 5years.) OFFICER OR AUTHORIZED AGENT CODE 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 may be Used. (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) PAGE OF <br />