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PERMITTEE NAMElADDRESS rlnrludr Facilih .\amr/Guatian iJllif/rrenrl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMA) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 20x0-000a . <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX NA <br />Y <br />I TYPE <br /> A <br />L <br />S <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ <br />I <br />~ <br /> MEASUREMENT ~ ' - -' <br /> PERMIT f ~ ~~ <br /> REQUIREMENT _ _ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I ' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ' ' <br />` <br /> MEASUREMENT ~ <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ~ <br /> MEASUREMENT ~l <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />~ ~- <br />I ~~ <br /> PERMIT - <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 crrtik under penalty o(Lre that thl+d~wunxnt and ull atlachmenro were TELEPHONE DATE <br /> prepared under m) direction or wprn i+ion in on~nrduncr with a+)Hem da+iemd <br /> lu x++ure Ihat yuulifird perwmnrl prop~rl/ Bather anti e+alurlc the inlonunlinn <br /> whmitled. Naxd on m~ imluln of Ihr prrwn nr penum aho manuee the +)+trm, <br />~ <br />, <br /> ur Ih:~• prr+nm dirn~tll re+p:m+iMr for gut M•rinRIhe infnrnutLm. tha• information ~ <br />~ <br /> +uhmiticd h. to the bra of nn AnuwlydRr aM belief. true, accurate. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ : • f <br />~ <br />- <br /> I am uwurr Ihot thur are +iRni(ram prnaltia+ for .ubmittinR ful+r information. AR <br />A <br />TYPED OR PRINTED <br />inrludinttthe prssibilih of fine and impri+onntenl fur Anowin¢ ~irdmirat.. <br />OFFICER OR AUTHORIZED AGENT <br />D <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments Here) <br />EPA Form 3320-1 (Rev. 3:5~~ Pre,~rous ad: _ _ may be u;c,i I~hi, i, ,t ~ i~tlr! t~ . rr:- <br />