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PERMITTIIE NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/bocatlonijdijferent) DISCHARGE MONITORING REPORT (DMR/ <br /> 2-16 17-19) Form Approved <br /> ADDRtss ` OMB No. 2040-0004 <br /> PERMIT NUMBER I DISCHARGE NUM BER - Expires 9-30-91 <br /> '�—`--- ------ MONITORING PERIOD <br /> FACILITY <br /> ------ 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 NO FREQUENCY SAMPLE <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) 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 /> PE1214#) <br /> IV$1�U#htfiMllittE'I` 4 y •, �8:i�i ;msil F <br /> SAMPLE <br /> MEASUREMENT <br /> /I�QtiIRIwI�Rff.I�I'I• . <br /> -. - ��_:� dry:_.1 - � ._a-.�_ ...»•».—....- ------.. .- ....- --- ... ....-�:-� -.•c s- .::z�—- --- �•- - _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERM IT f �k <br /> RE�C#UIREM I*N'}' . <br /> SAMPLE <br /> MEASUREMENTPERMIT <br /> - - <br /> REiiEllRZMENT <br /> SAMPLE <br /> MEASUREMENT <br /> RWU#REM ENT <br /> T <br /> M <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x <br /> R€GI#21IQCM ENT <br /> n <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,. „ .,. i r <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 J <br /> // • p ' ON MY INOUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR , f <br /> j1 �.- i''��(�'t T=. -- J/�, OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION -- f <br /> J/ <br /> IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG <br /> / NI F ICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING <br /> •�/ 'l,r+f I THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC 1 1001 AND -� '��? �'�Y�'1 �• <br /> 33 USC 41319 tPenaIt— under thew statute,. n ,I,I de (Ine. up to t101HY) SIGNATURE OF PRINCIPAL EXECUTIVE l <br /> TYPED OR PRINTED and of masmlum Impnnonmvnt o/hrtuwen 6 month.and i jean 1 OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) CODE <br /> EPA Form 3320.1 (Rev.948) Previous editions maybe Used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />