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PERMITTEE NAME/ADDRESS tln.•Indr Fnrilirr ~~mr /n~anun iJlhJfaenlJ <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <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 TO <br />Form Approved. <br />OM8 No 2040-0004 <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 <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 /> <br />PERMIT ~.,.,.,J <br /> REQUIREMENT - ~ '"' ~' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,• .. .. .. - ` ~ . , _ .. , , <br /> REQUIREMENT r ~ ~ ~" <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l cerUr~ under gndu) o(law that thi+dncumenta~ullrrtrobmen[cwcrt <br />r <br />d <br />ai <br />isi <br />with <br />t <br />i <br />d <br />Ai <br />• <br />i <br />d <br />d <br />d TELEPHONE DATE <br /> p <br />epon <br />un <br />er m. <br />n <br />nn or suq <br />n <br />ott <br />n aaror <br />ance <br />a sys <br />em <br />gne <br />es _ .. <br />. <br />- Ur >t~mrr that yualifkd per+omrel prnpetis gmhrr and es aluatr tM• Information <br />• <br />-'-'-- suhmilicd. Naaed on my inyu{n of the persrm or pcrs.m+ who mamRe the +y sent. <br /> or thou prrwn+dtrertly respnn+iblr for guthrring thr infnrmaU.m, the information , <br />• submitt •d ic <br />to the hest of m~ knowlcd~e atd bdkf <br />true <br />r+YUruc <br />and armplrtc. <br /> , <br />, <br />, <br />, <br />I <br />w <br />t th <br />m <br />lti <br />itti <br />i <br />lh <br />i <br />J <br />f <br />b <br />f <br />l <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am a <br />are <br />gn <br />ca <br />pena <br />or su <br />m <br />ng <br />a <br />n <br />ormat <br />a <br />ere art s <br />es <br />se <br />on, <br />Including the gMSihflih of fine and impriwnmenl for knnwinR+i.datlnns. <br />OFFICER OR AUTHORIZED AGENT AREA <br />C D NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,r99) Pfevious editaru may t>e used. This is 3 4-cart tOTITI. PAGE OF <br />