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PERMIWEE NAME/ADDRESS anch,deFmilityNowwdLocati—ijD�fgerent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br /> NAME DISCHARGE MONITORING REPORT(DMR) OMB No. 2040-0004 <br /> 12-16t (17-19) <br /> ADDRESS Approval expires 05-31-98 <br /> PERMIT NUMBER j I DISCHARGE NUMBER <br /> FACILITY MONITORING PERIOD <br /> YEAR MO DAY YEAR MO DAY <br /> LOCATION FROM TO <br /> (20-21) (22-23) (24-25) (26-27) (28-29) (30- 1) NOTE: Read instructions before completing this form. <br /> PARAMETER (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUANTITY OR CONCENTRATION NO FREQUENCY SAMPLE <br /> (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 (62.631 (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 MP <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 /> NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND TELEPHONE DATE <br /> AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN;AND BASED ON <br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br /> TRUE, ACCURATE AND COPLETE. I AM AWARE THAT THERE ARE <br /> SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 19 U.S.C.1 1001 AND 33 SIGNATURE OF PRINCIPAL EXECUTIVE <br /> U.S.C. 1 1319. (Phnaldes under these stetutes may include fines up to$10,000 AREA NUMBER YEAR MO DAY <br /> TYPED OR PRINTED and or mexwnutn k"pdsawwt of between 6 months and 6 ysars.l OFFICER OR AUTHORIZED AGENT CODE <br /> COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (08-95) Previous editions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />