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PERMITTEE NAME/ADDRESS Ilnrlude 1•tx•ildy .\'amdlrnatinn iJOrJJermtt NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 - <br />itSGNv^ T~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX Y <br />I TYPE <br /> ANAL <br />S <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ <br />/ <br /> MEASUREMENT ~ J 1~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~ ~ ~-~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~ ` <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~ <br /> MEASUREMENT '~ <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT i <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE 1 ' <br /> MEASUREMENT ! t `' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />! <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cent. under pa•n:dl? nrmw, that Ihi+diwumem and au auachnxm. were _ TELEPHONE DATE <br /> prrparrd undrr m? direction ar wtn•n i.iou in aararduncr With a y+tem Aniknad <br /> to awrc Ihat ywlifivd Iw•nonnel praprrh {;u1M•r and eaalunte the inturnmlinn <br /> wbmittavf. ISu.rd ..n m? inyuin ..f the pa•nnn ar prrwu+ who nwna4r tM• y+tcm. <br />~ <br /> ar tM::e pe n.nn direcd? n•+prm+ihie far I:atM•nny the information, Ibc information - <br />~ ~~ - ; <br /> llrt <br />lrvr <br />ce urale <br />and ram <br />lcle <br />A <br />al <br />nd t <br />h <br />f <br />d <br />• <br /> . <br />p <br />. <br />N <br />, a <br />. <br />wbmillad i+. In t <br />e Mtit o <br />n» <br />na <br />e <br />ea <br />a <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am aware that there arc +iFnifnant penaUie+ far whmilling fal.c infurmatiwt, ARE <br /> a.+ihilih of fine and imprbonment far knawinC.i:datirm+. <br />cluding the <br />i OFFICER OR AUTHORIZED AGENT E NUMBER YEAR MQ DAY <br />TYPED OR PRINTED p <br />n <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Aelerence all attachments here) <br />EPA Form 3320-t (Rev. 3'591 Priapus eaihon= may ~: ,•_,: ~ f hi. i, a ~-Dart (t~nli. <br />