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PERMITTEE NAME/ADDRESS (lncludr Faeifin \urnei(.vatinn if Ai(Rrnu~ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMRJ <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 20A0-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _. ._ <br /> REQUIREMENT - - <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT ~f <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I crrtifr undrr Ix•n:dn of lax that this document and all alacbmrnls xere <br />i <br />d <br />t <br />i <br />d <br />d <br />i <br />i <br />ilh <br />d <br />d TELEPHONE DATE <br /> un <br />ancr x <br />a sys <br />rs <br />gtm <br />prepare <br />umler my <br />irrrliun ur supen <br />s <br />n acair <br />em <br /> to assure that yualifird pr•rwnnel props rl> gathrr and esnluate the infnrn~alinn , <br /> submitted. Hasrd :m ms inyuin of tha• p•non or pennm xho mange Ihr syHem• ! <br />a <br />j <br />: ~ ~~ <br /> or those Ix•nuns directly nyp.nsiMe fur yd hrrinK the information, the In(nrmatiott am <br />< <br />~ / - <br /> and compklr <br />submitted is <br />b. the hest of m} 6naxledgr and M•lis•f <br />Irur <br />ucrurutr <br /> , <br />. <br />, <br />. <br />. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED 1 am ax an• that thrrr an• significant prnallie. fur suhmitting false information. <br />including the possibility of fine end imprisonmrnl for knowinK siolaliom <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Fan 3320-1 (Rev. 3199) Previous editiars may be used. . t~~0' This is a 4-part <br />