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PERMITTEE NAME/ADDRESS ~Indndr Facilfn ~amr/Lrxdrimt if Diffrrtn(I <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />~r~i~fA: <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM ((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 />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ,\ - <br /> MEASUREMENT ~ ~ ~~' I ~_ ~ ~ . ~,.' <br /> PERMIT - ' - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT - ' <br /> PERMIT - ` <br /> REQUIREMENT <br /> SAMPLE - <br />` <br /> MEASUREMENT ~ ~' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE II <br /> MEASUREMENT ~- 1 y ~ ~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br />~ <br /> MEASUREMENT j <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~ ~ 1 <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I arrtit) under prnalq td law Thal Ihi+d:rvrm•nl aml ull attxhma•nh weer <br />' TELEPHONE DATE <br /> prrpareA under my dira•ation or +utx•n iaiun in accunlmxa• with a y+4•m drsiXned <br /> d: u++urr That yualifird pr r+unnrl prnprrl~ Bulkier :md r. aluutr the hdnrnmti:xt <br /> yuhmittad. HaceA nn np inyuin of ihr prnnu ur Ix•r+un+ as hu mamry;r the y.frm. <br /> or thine prnnn+dirra ll. rr+pm+ihlr fur tadherink the infunmdiun, the information - <br /> +uhmiunl i+. lu the Ix•d of m~ IamaalcdGe and Ixlicf. trua•. arcuratr, :md aomlJrtr• SIGNAXURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am awun• that there are •ittnifrcnnt Innaltir+ fur arbmiuinl; fakir in(urmutiot4 <br />imludinK for Iwnaihlity of fine wxl impri+onmrm for Anowinp aiu7atiun+ OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />PAGE OF <br />EPA Form 3320-1 (Rev. 3199) Previous edrhons may be used. Th'ts' Iti a 4-I?drt fnI'nl. <br />