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PERMITTEE NAME/ADDRESS Ifndude Fnri(in• .\'axrrl[arutinn iJDiJJrsentl <br />NAME <br />ADDRESS - .. <br />FACILITY <br />•~ LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />Form Approved. <br />OMB No 2040-0004- <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />• FROM TO <br />P9:~}~.IF'-., . NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE a / <br /> MEASUREMENT `• <br /> PERMIT • <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br /> <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 ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT = <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER t'~TI'r! undcrPc•n:dtr of law Thal Ihi+drkumentarwluuanarhmcnt..`e"' <br />nvl <br />Uu <br />ri+ion fn <br />~urdancr with u <br />dem Arsignrtl <br />r <br />d. <br />n <br />di <br />.r <br />• TELEPHONE DATE <br /> .u{n <br />y <br />p <br />epu <br />un <br />r <br />n <br />nr <br />n . <br />r <br />xn <br /> lu acwrr Ihal yu.dified penonm~l pngw~rl) >:alhrv and e+nlnap• the iufunnati,Hl <br /> ulbmiu+d. Rued wn m+ inyuin of tt:c pennn or prrv;nc who mnna~e thr .~ stem. <br /> or th,wr Iverson. dirertlc n q,n.iblr for katherink the inrormution. thr inL,rm:Aiun '-1 <br /> suhmiUrvl i+, 1~~ the M~.t ..f m. knnwlydRe and Iwlirf. Inm, ueeut•atr, and cnmylrlc. <br />h <br />th <br />if <br />t <br />dti <br />h <br />uu <br />f <br />f <br />thn <br />I <br />r <br />l <br />i <br />SIGN~TURE OF PRINCIPAL EXECUTIVE I <br />~~ <br />_ <br /> <br />OR PRINTED am awve t <br />.d <br />em:ue.lkn <br />lrrn <br />e+ <br />nr+u <br />m <br />nK <br />n <br />ormu <br />. <br />pem <br />a <br />u <br />inoluding th, i 1i1+ ~d fi,w• and im n nmenl for know in , , IuG~m•. <br />~~,,,i ~~ n +'~ ~+ Of~ICER OR AUTHORIZED AGENT NUMBER <br />A YEAR MQ DAY <br />TYPED ODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. y99) Previous edtions may txa used. This i. a 4-{tort form. <br />