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PERMITTEE NAME/ADDRESS pnclude Facility Name/Locahon i~DiffrrenrJ
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 7 1 1; TO " i C] 31.
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: ~ Read Instructions beforetom~pleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION N0. FREOUENC SAMPLE
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<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
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<br />NAME/TITLE PRINCIPAL E%ECUTNE OFFICER I Cediy antler penalty of law Ihat this document end all attachments were TELEPHONE DATE
<br />l Y- preparetl under my direction or supervivon in accordance with a system designed
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<br />SIGNATURE OF PRINCIPAL E7(ECUTIVE tp/ S G
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<br />TYPED OR PRINTED I am aware that Nere are srgmfcant penalties for submiNng take iMOrmatmn'
<br />inclutlin the ossibili of fine and im risonment br knowi violations. OFFICER OR AUTHORIZED AGENT
<br />D NUMBER YEAR MQ DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attacnmenrs Here)
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<br />EPA Form 3920.1 (REV 3 9) V rev~TUS a itions may be used. THIS IS A 4-PART FORM PAGE 1 OF
<br />GGol:'/::' 0717- L "1 ..
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