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PERMITTEE NAMEIADDRESS ~fnrle~Ar F'atifih ~nmt f u„ni,~n i1 hi/lrrrnr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE i ~ ~ i <br />• MEASUREMENT r• ' r =-'L~ <br /> PERMIT .. _ „ <br />~ ' ~ ,~ ~ - <br />~ ~ ~{ ' <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEffITLE PRINCIPAL EXECUTIVE OFFICER I .ortify under penalty of law that thi+d,aruma•nt and all atwchnrrnt+werc <br />i TELEPHONE DATE <br />_ prepared under m+ d{rratiun ur eupen ision in accordance with ~ +cNem dr+ <br />gnarl <br />- ~ to a: wrr that yuulifiad prnonnrl prv,prrh gathrr utd e. alwur dte information <br />~ <br />' whmithd. Na+ed on my inyuin of the person ur perwn+.r hn manuKr the +r+tem, <br /> or th,nr ix•nnn+dinatly re+punsihlr for gathrrin>< the mfurmation. tlm information . ~ ~ • <br />~~ i +uhmittrd L+, to the bc+t .~f m. kn~wkdge unU hrlief. true, uccurutr. and complete. <br />i <br />f <br />i $1GNATURE OF PRINCIPAL EXECUTIVE , <br /> <br />TYPED OR PRINTED I am awaty that thrrr are .it!niTcum penaltia. fnr+ubmittinq fal+e <br />n <br />ormat <br />on. <br />Imluding the p,nsihiliq of rma :md impri+nnment fur Lnawln~ +iotutions. QFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MQ DAY <br />COMMENTS ANU tJ(YLAIVAIIVrv yr ArvY <br />EPA Fofm 3320.1 (Rev. 3/99 <br />Inererence au attacnrnrnts ncre~ <br />GE pp <br />