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PERMITTEE NAME/ADDRESS ilnrltlde Facility A'axte/Location if Ui,(]eruul <br />NAME <br />ADDRESS <br />I FACILI? r <br />LpCAT!CN <br />~. rT ~ I r'TGla <br />:F PFiF~i <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 />Form Approved. <br />OMB No 2040-0004 <br />TI? i D Ti <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PEAMIT - <br /> REQUIREMENT ' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT >• <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , ;rt~ - _ - ~ .- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT " f~E Jig • <br /> REQUIREMENT _ _. .. ~: ~'~. i L Y ~-' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccrtd} ulldcr prnalh of law thrl Ihi+dlKLVnnl and all attachment. wen <br />eni.inn in slernrdancr with a <br />slem d~i <br />md <br />I <br />nAe <br />din <br />tio <br />nr TELEPHONE DATE <br /> ry <br />>; <br />prcpan< <br />u <br />r m~ <br />r <br />n <br />wp <br /> In a Sort Ihat yualifio<I pcrwnm•1 pmpl•rl• galhcr mnl c~ahmte the information <br /> whmitad. Bald on nl~ inyuin or the pry+on nr penone who mnoagr Ihr cateln. <br /> or Ihnu prrW/nc dirrc•Ih retiplncildl• cur t;ntlu•riI1R the infn-mutH/n. Ihr infornwlion ~ i - " <br /> .uhmiU.d is, to the Ix+t ~~(m~ Auowladge •rnd helk•f, trw, wcuratr, and cumpkle. <br />w <br />re that Ih <br />nificant <br />x•nalties roc wbmiltin <br />roles inrormatinn <br />I <br />r <br />si <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED R <br />• <br />am a <br />a <br />e <br />e are <br />g <br />I <br />ilnluding Ihr plx+ihility or fine oml imprirlmmenl for knowing ~il>fatium, OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />0 YEAR MQ DAY <br />GUMMtrv I, ArvIJ enroll\r I wn Vr /il\ <br />NI IVI\J (r1C/C/C//{GC OI/ Ollpl.l/I/ICIIIJ I/C!C/ <br />I EPA Form 3320-1 (Rev. 3/99) Previous edipotls may be used. "`O'. This is a 4-part form. <br />