Epa Form 3320-1 (Rev. 9-88) - Discharge Monitoring Report (Dmr)

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PERMITTEE NAME/ADDRESS (Include
(NPDES)
NATIONAL POLLUTANT DISCHARGE ELINIMATION SYSTEM
Facility Name/Location if different)
DISCHARGE MONITORING (DMR)
NAME
(2-16)
(17-19)
Form Approved.
ADDRESS
OMB No. 2040-0004
PERMIT NUMBER
DISCHARGE NUMBER
Approval expires 10-31-94
MONITORING PERIOD
FACILITY
YEAR
MO
DAY
YEAR
MO
DAY
LOCATION
FROM
(20-21)
(22-23)
(24-25)
(26-27)
(28-29)
(30-31)
NOTE:
Read instructions before completing this form.
(4 Card Only) QUALITY OR CONCENTRATION
Parameter
(3 Card Only)
QUANTITY OR LOADING
No.
FREQUENCY
SAMPLE
(32-37)
EX
0F
TYPE
AVERAGE
MAXIMUM
UNITS
MINIMUM
AVERAGE
MAXIMUM
UNITS
(62-63)
ANALYSIS
(64-68)
(69-70)
SAMPLE
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT REQUIREMENT
SAMPLE
MEASUREMENT
SAMPLE
MEASUREMENT
I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED
TELEPHONE
DATE
NAME/TITLE PRINCIPLE EXECUTIVE OFFICER
AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED
ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION IS
TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT
PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY
OF FINE AND IMPRISONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C. §1319
(Penalties under these statutes may include fines up to $10,000 and or
TYPED OR PRINTED
SIGNATURE OF PRINCIPAL EXECUTIVE
AREA
NUMBER
YEAR
MO
DAY
maximum imprisonment of between 6 months to 5 years.)
CODE
OFFICER OR AUTHORIZED AGENT
COMMENT AND EXPLINATIN OF ANY VIOLATIONS (Reference all attachments here)
EPA Form 3320-1 (Rev. 9-88) Previous editions may be used.
(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED).
PAGE
OF

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