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PERPITIME NAME/ADDRESSQndudeFmilavNaneiLocanonlrDifjerent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br /> NAME DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br /> _ (2-16) (17-19) <br /> ADDRESS I I Approval expires 05-31-98 <br /> PERMIT NUMBER I DISCHARGE NUMBER <br /> FACILITY <br /> MONITORING PERIOD <br /> LOCATION FROM <br /> YEAR MO DAY TO AR YE MO DAY <br /> (20-21) (22-23) 124-251 (26-271 (28-29) (30-31) NOTE: Read instructions before completing this form. <br /> PARAMETER (3 Card Only) QUANTITY OR LOADING (4 card Only) QUANTITY OR CONCENTRATION NO. FREQUENCY SAMPLE EX <br /> (32-37) ��. � 146-53) (54-6fl (38-45) (46-53) 154-61J OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS TYPE <br /> 162-63I /64-66) (69-70) <br /> SAMPLE ! <br /> I M(:4SUREMENT <br /> PERMIT <br /> REQUINEN:ENT <br /> -- - --- SAMPLE � -� -- — - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLF: <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 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 COMPLETE. I AM AWARE THAT THERE ARE <br /> SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. 1 1001 AND 33 SIGNATURE OF PRINCIPAL EXECUTIVE U.S.C. S 1319. Merddos under drese sbtutes msy include lines up to$10,000 AREA <br /> TYPED OR PRINTED and or masimuntkronsonment of between 6monthsand 6 years.) OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 108-95) Previous editions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />