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PERMITTEE NAME/ADDRESS tlnrludr Facilirv ~'amr/!oration iflhff~rrnrl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONCCORING REPORT (DMR) <br />NAME <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />N0. <br />EX FREQUENCY <br />~ <br />ANALYSIS <br />SAMPLE <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />ASUREMENT <br /> ME <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l rortir. under penalq of Ina thnf Ihis drw•umem and all attachments wrrr <br />prrpurrd undrr my direction or wpenision in accordance with u q:sletn daKigned <br />_ TELEPHONE DATE <br /> to tnsurt t11at qualiRrd pcrwmnel pmpert~ Rather onA evaluate Ihr information <br />suhmitled. Rasavl nn my imluin of the penrm nr persnrt who munagr thr system. <br />the information <br />the infonmtion <br />rin <br />fo <br />th <br />7 <br />ibl <br /> . <br />e <br />r ga <br />e <br />g <br />~ respons <br />or those penans dinrl <br />.ubmiued i , to the he+t of ms knnwlydgr and hrlief, true. uccunlr, and compktr. <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />- <br />- I am swan that there arc significam penaltio for svbmiuing falx information. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br />TYPED OR PRINTED including Ihr pmsihdiq of rim• and imprisonment for knowing vitiation. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />':'~ ~ ; This is a 4-part form. <br />EPA Form 3320-1 (Rev. 3199) Previous editlorts rosy be used. <br />