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PERMITTEE NAMElADDRESS!lnrlude Fl(rilut ~~~md(aa~a(inn iJ!)iffrrrr(tl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING 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 />MI! <br />~~I <br />Form Approved. <br />OMB No 2040-0004- <br />NOTE: Read Instructions before completing this form. <br /> QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br />PARAMETER EX ANALYSIS 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 /> MEASUREMENT <br /> <br /> PERMIT • <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT -•" ,~ <br /> <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ~ f - ~ <br />~ .. <br /> MEASUREMENT 1 ~ ` <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 ~ rnih undrr p•nalh ..f lam that mi. d~KUmrnt and au wwehmrm. errs TELEPHONE <br />d DATE <br />prepan•d order nn diraviion ur .upa•rvi~ion in oat ordanrr wnh a .a ctrm dr.i>;nr <br />w uaatrr that yuulifia-0 Ix•twnnrl pn~perl~ gathrr umI c~ulunte the inlonnation <br />.ubminrd. Na.ed on ma inquire of the person or q•rwm. who manat;c tha• a~.tem. • <br />ur Ih~na• person. dirertl~ rrap~m.ihlr fur gatlterinK thr infurmatirm. the inlnrmation <br />.uhtnittarl I., to the IK.t of m) AnowloJ>;r and IH•lia•!. true. ucaur.Ue, and cumplrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aeare that than an•.iKnificant penalGa+for.uhmirlinK fuHa• iidurmatiun. OF(?ICER OR AUTHORIZED AGENT AREA <br />R <br />YEAR <br />MQ <br />DAY <br />TYPED OR PRINTED inaludinK the p...ihiliry o! firer and inrpria~mntem GK AnowinK violation. D NUMBE <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS Irre-erence au arracnmenl, ttr;aa <br />~. ~ ~ rtnr:- ~•G [. ~ 74f'H ~:!~fa.~i''.3 ~i ~.-]:-•. --- <br />EPA Form 3320-1 (Rev. 3/99) Prevrous editions may be used. ~ I11 " .t ~ i ..I! ~c~l nt. <br />