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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES) FOrm ApprOVed. '
<br />DISCHARGE MONITORING REPORT (DMR) OMB NO. 2040-0004
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<br />YEAR MO DAY YEAR MO DAY
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />R AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS auaLVS/S
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I Ced:y under penalty of law that this document and all anachmenLS were
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<br />i SIGNATURE OF PRINCIPAL EXECUTIVE ~ r: - !p ~~
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<br />TYPED OR PRINTED ake informat
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<br />I am aware thaz mere are signNCarrt penalties for submining
<br />Includin the ossibili of me end:m risonment for knowin violations. OFFICER OR AUTNORIZED AGENT AR
<br />NUMBER
<br />YEAR
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<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
<br />M)721/OJ0717-1350 ;.
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