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PERMITTEE NAME/ADDRESS Ifnrludr faci~irr ~'mnri(wu~arton if Diffrrrnh NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />MI <br />J <br />1= <br />Form Approved. <br />OMB No. 2040.0004 <br />)r:A1:tU.~ICxE TO GUi•:~•II`~C <br />ti~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - ~ - r <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 - F . ,- <br /> REQUIREMENT _ <br /> _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT rf_i=fats r ::.,.- ..- <br /> REQUIREMENT ''ti;•~. .=, _ - <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I rertif~ under penalh of law Ihut thi+dvtvmrnt and tdl alWChment+werc <br />d <br />' <br />' TELEPHONE DATE <br /> atrdance with ~ wntrm <br />e+rytnad <br />prepared under m~ <limlion ur wprn <br />r.inn hr w <br /> to w.+urc that yualifird prrwnnel pruq•rly ttather and ea ahmle the informwion <br /> whrnittrtl. Kaxd ~m m. inquire wf the Iw•rum or per+uns w ho manage the .} atom. <br /> or throe perxm+dirrclh re+pon+ihk fur Qathrring for inlnrtrration, the information - <br />' ~ - <br />' - whmittd fa Iu the lira of my Anuwlydge anti Irvlkf, true, xcrunde, end complete. SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />J <br />TYPED OR PRINTED I am aware that tttrrr are +ignificunt prnaltie+ for .uhmittin>; fal+t• infurmati.aa• <br />includin{t the puacihiliq of fine and impri+unment for knuwin¢ riolation. OFFICER OR AUTHORIZED AGENT AREA <br />D NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANA l wrv Ur ANY VIULA I IUNJ Irreference an arracnmenrs nere/ <br />EPA Fom 3326-1 Re~: .. Prgv~ous _a~, ,~ : ~n=.. . - -. <br />This is a 4-part form. PAGE of <br />