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Form Approved. <br />PERMITTEE NAME/ADDRESS tlncladt Facility ,\'amdlarafiun if lhff~rnut NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ OMB NO 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />f'~I <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION I~Q, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. .. <br /> REQUIREMENT ' I+° <br /> SAMPLE _ <br /> MEASUREMENT <br /> <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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ . <br /> REQUIREMENT " <br />NAMEffITLE PRINCIPAL EXECUTIVE OFFICER I «rtiry under penalty of law that this dxumrttt and all uttochmcnt. wcrr <br />i <br />h <br />{ <br />d <br />d <br />d <br />d <br />• <br />i <br />i <br />d <br />d ~ t TELEPHONE DATE <br />_ er mr <br />ance w <br />u .rstem <br />prrpun <br />un <br />trcrtWn nr wp< <br />r+ic <br />nn <br />n xcor <br />t <br />re <br />Kce ~ <br />e <br />' ~ ~ f Q ii'u.~ r ~ . ~. G / .--1 r to awwre that u:difird rwnnrl r rh other and rs alua[r the infarmutian <br />4 Pe P oPe K / ~ , . <br />/ <br /> suhmiui¢I. Raw•d on my inquin ~d the prrw~m ur pcrwm+ who matw~r the ss+trm. ~/~f <br />l <br />_ ur those {rerwn+dirn ll7 rr+punsible fur gutherinK the information. the infurmnliun ~ ~~'` - ~ <br />" ~ i ~ _.> 51/4mllted It, Io the first of m\ hm~wlydRr and hclkf. Irur. alrnrlllr, and r~Nllplf/e. <br />itti <br />ti <br />h <br />th <br />i <br />if <br />t <br />lti <br />f <br />h <br />f <br />l <br />i <br />f <br />I <br />- SiGNATLIAE OF PRINCIPAL EXECUTIVE ~ ~ - <br /> <br />TYPED OR PRINTED am aware t <br />ievn <br />prnu <br />n <br />orma <br />on. <br />at <br />ere arr s <br />pn <br />es <br />or su <br />m <br />nK <br />a <br />se <br />includin the vbilit~ of fine and im rt nmrm for knnwin iolution+. <br />tt Pa " P ~sn R s OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />I P F.VE~iT '~c5 <br />EPA Form 3320-1 (Rev. 3199) Previous ed+tiorts may be used. Utz f i This is a 4-part form. <br />