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PERMITTEE NAME/ADDRESS ilncluAr Facility \ome/lnration iJlk;(Jmn1 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((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 />M~ <br />~~ <br />1= <br />Form Approved <br />OMB No. 2040-000-. • <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ <br />r•J <br /> MEASUREMENT ~ <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ' <br /> MEASUREMENT ~ • <br /> PERMIT <br /> <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 /> <br /> SAMPLE <br />~ <br /> MEASUREMENT ~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> <br /> PERMIT <br />- <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 aenir> under prnnltr u/law that thi, d:r'uma•nt end all ultarhmcnl, werc TELEPHONE DATE <br /> prep-erad madrr m~ direruwn ur ,upa•n i,iun in +ecurdunce with u c„tem Ae,iKmd <br /> Iw u,uva• that yuuliRnl pennnnel pnq:erly (valhrr um1 c, nluutc the informaliun <br /> ,uhmiurd. Na,rd :ut my inquin of the pennn or {rrrwn, whw manuKr the y,tem, l <br /> nr th::.r prrwms direrth rarpna,iMe fnr Kuthrrink tha• infwrmution. the in(urmuuun <br /> ,uhmittad iti to the tn•,t o! m~ knwwiedKr and helic(, true. uccuratr. and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 um aware Ihal thrre are ,iKnifu~nnt penultie, fnr whmltlintt frl,a• infurmuliwn' <br />THORI <br />ENT <br />R <br />R A <br />A AREA <br /> ri,nnmrnt fnr knuwinK violulion>. <br />ibilih of f <br />nd im <br />th <br />l <br />di O <br />U <br />ZED <br />G <br />OFFICE ~ NUMBER YEAR MO DAY <br />TYPED OR PRINTED e po„ <br />ine a <br />p <br />inc <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. 3x991 Previous editions may be use`.' <br />