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PERMITTEE NAME/ADDRESS Include Ftui(i!~ .\'amr/lra•aliun iflHffrreNr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY j•.al,; ".. ~ = MONITORING PERIOD <br />LOCATION I A YEAR MO DAY YEAR MO DAY <br />FROM TO <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO- <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ... _ .. r ,... r <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PEflMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERM17 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ~~'~ tin :order penalq o! lax that this docun~nt and all attus$meNs were <br />d <br />tio <br />i <br />~u <br />with a <br />st <br />d <br />si <br />l <br />d <br />di <br />i <br />l <br />d TELEPHONE DATE <br /> yrepare <br />un <br />er my <br />rec <br />n or wprn <br />s <br />on <br />n wv <br />r <br />unce <br />sy <br />em <br />gtar <br />a <br />to aswrr that qualified perwnnrl prnprrl~ gather and esaluutr tlur information / <br />~ / <br />~ <br />1 r submitted <br />Ba+ed un mr in <br />uin of the <br />rr.on or perv~rrc who manage the system ~ <br />~ <br />" I , <br />. <br />y <br />p ~ ~ ~ <br />~• /' <br /> or throe persons dirarth rogmsihle far gathering the inlormaunn, the information ~ <br />'t ~ submitted is, to for best or my knowledge and belief. True, accurate, and cnmpkte. <br />w <br />th <br />t th <br />nifi <br />t <br />lti <br />b <br />l <br />l <br />i <br />f <br />ti <br />n <br />I <br />i <br />! <br />itti -- - - ' ~ <br />SIGNATURE OF'PR-NCIPAL EXECUTIVE - <br />~~ <br /> nor a <br />are <br />a <br />em are s <br />g <br />can <br />penu <br />or su <br />m <br />ng <br />a <br />sc <br />n <br />orma <br />o <br />, <br />s. OFFICER OR AUTHORIZED AGENT A`R <br />TYPED OR PRINTED inrludingthepussihilit7 nffinrandimprls~mma•mfurknuwing.idution pE NUMBER YEAR MO DAY <br />NOTE: Read Instructions before completing this form. <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />'1'Iti~ i~ 9 ~-~ <br />4GE OF <br />EPA Form 3320=1 (Re <br />