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PERMITTEE NAME/ADDRESS pnclude Fanltiy NamdLocaHOn I/Digerenq <br />NAME <br />ADDRESS ~ ~,- •~ ~ ~ - <br />FACILITY - -~ <br />LOCATION <br />,'r-' - <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESJ <br />DISCHARGE MONITORING REPORT (DMA) <br />PERMIT NUMBER DISCHARGE NUMBER .I <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM -' TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before~tmlpleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX oP TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />•~ SAMPLE ~ ~ ~ ~ ' <br /> MEASUREMENT • <br />..:. :u+: l_ •: PERMIT ~ -. ~- ~ .: <br />~ ;_.~ „~~ <br />~ <br />~ .. _ -~- <br />-- ~ •i •:,:) ~~ ~ _ REQUIREMENT , , <br />. .'.L ~ _.. ': -.-. SAMPLE .. ,~ <br /> MEASUREMENT <br />- ~ - -~ PERMIT <br />~. r. ~ , ~ REQUIREMENT <br />- ~.. SAMPLE ~ ~ .. <br /> MEASUREMENT <br />_ . PERMIT .. - _ . <br /> REQUIREMENT <br />-. ~ :-:, . SAMPLE <br />~_ - MEASUREMENT <br />'. -. _ PERMIT ~ ~ - - - - <br /> REQUIREMENT <br />~.:. - SAMPLE <br />- MEASUREMENT <br />_ <br />r '_ L' _. -' PERMIT .. , . ~.:: ,. - <br />- _ ~ REQUIREMENT <br />' i L - SAMPLE <br />- MEASUREMENT <br />:' ~ ~ ~ PERMIT - , y - ~ ... - <br />- ~ ~ REQUIREMENT - - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER ICeAiry under penalty of law that this documam antl all attachments were <br />d <br />tli <br />l <br />i <br />i <br />i <br />tl <br />i <br />M <br />tl <br />h <br />tl / i TELEPHONE DATE <br /> prepare <br />un <br />er my <br />s <br />on <br />n acwr <br />gne <br />recT <br />on or supe <br />ance w <br />t <br />a system tles ~ _ ~ <br />_~ <br /> W aeaure That qualifietl personnel properly gather antl evaluate the information ~ ~ <br />~e ~ ' '~/. ~ L submlpetl. easetl on my Inquiry of me person or persom wtq manage the system, ~ ~ ~ <br />/ ~ ~ ~ <br />- ~ ~ .., i / ~-+ <br />• <br /> or Nose pereone tlkectly responsible br gaNering the Inlonretion <br />Ne IMOmiehon ~ ~ <br />~~ I ~ -e V <br />~ <br />v , v ~ ~ <br />i <br />, e , y, , . submmetl is , to Ne best of my knawletlge end baliel, we, accurate, end camptate. <br />N <br />l SIGNATURE OF PRINCIPAL EXECUTVE " l <br />- TYPED OR PRINTED I em aware mm <br />ere are significare pena <br />hea br submitting false IMOnnabon, <br />Indudin the ssibili of line end ~m risonmeni for knows violations. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMEN I S AND EXPLANATION UH ANY VIOLATIONS (Nererence all attachments Here) <br />EPA Form 3320-1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF <br />- r <br />