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PERMITTEE NAME/ADDRESS ilndude Farilitr ~'ameJl.rxntion ij(NffirenU <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION -: =? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMRJ 7+ <br />( <br />PERMIT NUMBER DISCHARGE NUMBER f <br />1' <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 _ <br />~.. <br />NOTE: Read Instructions beforecompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX ANAL TYPE <br /> YSIS <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 /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT ~.~: <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' ' <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT ' <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I ~irtitr nndrr prnulh of m~ mat this dnrurm•nt and :+u atw~hmurr. ~rrr TELEPHONE GATE <br />prepared nndrr nq dirrcti,ar ..r +uln•n i.ion in w~«udancr with u ,y+trm dr+i¢md <br />Iv u+.ure that :pulirird prn..nnel prr.prrl~ anther :md r~uluulr tlrr infurnrution <br />whmillyd. !toad on nn inyuin of thr pr•r,on or prr+om who munnge thr +y.tem. <br />or thox pennm dinclh respr.n+i Me for getha•ring ihr information, thr information <br />f <br />eubmHtrd i+. w the hr y of m~ know ledgr and hrlirf, tnn~. acn,rale, and complete <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there urr+ignirrcant prnahte+ for mbmiuing fal+e information, AR <br />A <br /> mribdin of lino and impri+onmrm for knowing .iolaliom• <br />Includin <br />the OFFICER OR AUTHORIZED AGENT O <br />NUMBER YEAR MO DAY <br />TYPED OR PRINTED g <br />p <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous edltiorls may be used <br />•t ~', Thi, fs a ~-dart farm <br />PAGE OF <br />