MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report State Form 30530 (R2 / 8-07) FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Facility e-mail address: I N 0 PERMIT NUMBER EFFLUENT CHARACTERISTICS EFFLUENT PARAMETER NUMBER SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum UNITS = Tue 1 Wed 2 Thu 3 Fri 4 Sat 5 Sun 6 Mon 7 Tue 8 Wed 9 Thu 10 Fri 11 Sat 12 Sun 13 Mon 14 Tue 15 Wed 16 Thu 17 Fri 18 Sat 19 Sun 20 Mon 21 Tue 22 Wed 23 Thu 24 Fri 25 Sat 26 Sun 27 Mon 28 Tue 29 Wed 30 Thu 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE FLOW Q C MGD HI 0 OUTFALL NO. 0 1 MO. 8 0 8 YR. 01/1/08 pH C Q LOW LB/DAY Q MG/L C LB/DAY Q MG/L C LB/DAY MG/L NO. OF TIMES WEEKLY, DAILY, MONTHLY EFFL. LIMITATIONS EXCEEDED TOTAL FLOW 0 I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief, true, accurate, and Signature of Certified Operator Date (month, day, year ) Signature of principal executive officer or authorized Date (month, day, agent year ) complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report State Form 30530 (R2 / 8-07) 0 FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: I N 0 PERMIT NUMBER EFFLUENT CHARACTERISTICS Q EFFLUENT PARAMETER NUMBER SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum LB/DAY UNITS= Tue 1 Wed 2 Thu 3 Fri 4 Sat 5 Sun 6 Mon 7 Tue 8 Wed 9 Thu 10 Fri 11 Sat 12 Sun 13 Mon 14 Tue 15 Wed 16 Thu 17 Fri 18 Sat 19 Sun 20 Mon 21 Tue 22 Wed 23 Thu 24 Fri 25 Sat 26 Sun 27 Mon 28 Tue 29 Wed 30 Thu 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE C 0 OUTFALL NO. Q MG/L Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 C LB/DAY 0 1 0 8 MO. C Q MG/L LB/DAY YR. Q MG/L C LB/DAY MG/L NO. OF TIMES WEEKLY, DAILY, MONTHLY EFFL. LIMITATIONS EXCEEDED Signature of Certified Operator I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Date (month, day, year ) Signature of principal executive officer or authorized Date (month, day, agent year ) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report State Form 30530 (R2 / 8-07) FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: I N 0 PERMIT NUMBER Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 0 OUTFALL NO. 0 1 MO. 0 8 YR. EFFLUENT CHARACTERISTICS EFFLUENT PARAMETER NUMBER SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum UNITS= Tue 1 Wed 2 Thu 3 Fri 4 Sat 5 Sun 6 Mon 7 Tue 8 Wed 9 Thu 10 Fri 11 Sat 12 Sun 13 Mon 14 Tue 15 Wed 16 Thu 17 Fri 18 Sat 19 Sun 20 Mon 21 Tue 22 Wed 23 Thu 24 Fri 25 Sat 26 Sun 27 Mon 28 Tue 29 Wed 30 Thu 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE NO. OF TIMES WEEKLY, DAILY, MONTHLY EFFL. LIMITATIONS EXCEEDED I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personne l properly gather and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Signature of Certified Operator Date (month, day, year ) Signature of principal executive officer or authorized agent Date (month, day, year ) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com