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PERMITTEE NAME/ADDRESS Qnclude Fanliry Nmnr/(ocadon IfAfferenr) <br />NAME <br />ADDRESS <br />'. ~ L <br />FACILITY ~~ <br />LOCATION <br />1 <br />NATIONAL POLLUfANi DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMA) OMB No. 2040-0004 <br />- •. <br />PERMIT NUMBER DISCHARGE NUMBER ~ _ 1 <br />MONITORING PERIOD ~ ~ ~ •,. ~ ~~ ~.. .: .. <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO - ~ ~ ' <br />NOTE: Read Instructions before cofipleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FflEOUENC SAMPLE <br />PARAMETER EX of TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~'~~~ <br />~. '. ~ SAMPLE . ~ - ~ .. <br />_ ~ MEASUREMENT ~. ~ ~ <br />.. ~...,... -, t; PERMIT - ~ - - <br />- •.,1 I ~ REQUIREMENT ~ - - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER ICerNy under penalty of law Nat this tlocument antl all attachments were <br />d <br />d TELEPHONE DATE <br /> prepan <br />un <br />er my tleecl¢n or supervision in exortlance with a eysYem tleaignetl ~ <br />• - 1¢ assure Nat qualifietl personnel properly gaNer entl eveluaU me Inlormetion ., ~ <br />- ~ ~ ~ aubmittetl. Basetl on ny inquiry of the person ar persons wbo manage Me rystam, ' - <br />~ <br /> or move pereone directly responsible ror gethanng the inlormation, Ne Inrormation ~ - <br />~ ' I ~ ~ - ~ <br />' ~ ; . I ~ ~ eubmmed le, ro the beet of my knovAeoge antl belief, we, eaurete, end wmplete. <br />I am aware That th¢re are <br />l <br />nAi <br />nt <br />n <br />ls <br />ror <br />itti <br />b <br />f <br />l <br />iM <br />tl SIGNATURE OF PRINCIPAL EXECUTIVE -_ <br />~, I • <br />TYPED OR PRINTED g <br />pa <br />s <br />ca <br />a <br />es <br />su <br />m <br />ng <br />a <br />se <br />Ornla <br />on, <br />inclutlin the sibil, ¢f rine and im dsonment ror knowin violations. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION 01= ANY vluu+I wN5 (Hererence aft attachments here) <br />EPA Form 3320-1 (REV 3/99) Previous editions may be used. ~ ° ~ - -" ~ ~ ~ ~ ~ ~ - THIS IS AHIS IS 4~PART FORM- PAGE- OFFORM- PAGE- OF <br />/~ i--_ - , <br />