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PERMITTEE NAME/ADORESS dnrlude F'ariltiv A'a//u/lnrution if DiffrrrNi NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY ,, MONITORING PERIOD <br />LOCATION Jti:L . YEA MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040.OO~a <br />NOTE: Read Instritctinn5 hPfnra r-mm~lPfina this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />E of <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~~-` ' <br />~ <br />~_. MEASUREMENT ~ f <br /> PERMIT -~ a R#~ ti .. -. r- ~-: . <br />= REQUIREMENT - ~Vi- , - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -F ' -.rte--sr-x zs; i-,= '•,r. - <br />' REQUIREMENT -~ :; f;1 I__ : i`3 J~ <br /> SAMPLE <br /> <br />MEASUREMENT __ <br /> PERMIT - ti• a s :~-~ ., - ". <br /> REQUIREMENT .:i~, - <br /> SAMPLE ~ <br /> <br />MEASUREMENT , <br />- ~ _ <br />-~ ` ;_,.. ~ <br />`~ <br />, ~ , <br /> PERMIT -;r' r7 1 I ~ , - -t: -. . ~ ~ , ~: _ ,.-, , r - <br /> REQUIREMENT ilia 1 L. •:~ •• -• • <br /> SAMPLE ' <br /> MEASUREMENT ~" `.N 'I <br /> PERMIT .. y. I . ~ ~ _, - • , ~ L . .. ~ . <br /> REQUIREMENT I ' ;'=, ~ c, ~ z• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtif7 wider Ix•nulh of law that this docwnrnt and all uttarhmon[s were <br />I d <br />d <br />d <br />l <br />t <br />' <br />' TELEPHONE DATE <br /> prepare <br />lln <br />tr m <br />Utl ar Wl,er\ <br />lrKl <br />\Inn In Ull <br />ofd'JM <br />t wl[h a w.lrm deslgMd <br /> to u.wrr that ylulifkd prnonnd properh gullMr and c\aluutr the inB,rmution ~__~ _ . <br />- _ -______-- wbmiurd. Flu.rd .HI mi inquiry of the pc•r.on ur prl~ua+ wha manage Ihr .~.tem• ~' <br />- or tMne pc•nuns directh rrsprln\ihlr for >tialthering Ihr information, the infornultlun -- n _ <br />_ <br />- <br />~ .uhrtlitted l., to the hc\t of m\ knnwled>te and helkf, tear, attvrutc, :Ind complete. , <br />P ~ j - _ , <br />_ I am aware that there are \ittnlfwrm penultir+ for whmittiuk ful.e infurmutilm SIGNATURE OF PRINCIPAL EXECUTIVE - i ~-' v <br />TYPED OR PRINTED • <br />inrludinK the pn..ihilih of fine and impri.unmrnt for knowing \iulatioas. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />DE YEAR MO DAY <br />V VIrIrrI l~IrIJ MIrV G/\t"LMI\M IIVI\ Vr MIDI rIVLMIIVIrJ 1r1CIC/CIIt:C tl/I tlf[r7L/7//ICI![7f IIClC~ <br />EPA Form 3320.1 (Rev. 3,`99) Previous editioru may De used. <br />~17i~ i a -; '.trt t~Irnl. PAGE OF <br />