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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<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
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before completing this form.
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ,
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty oFlaw that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />G j U ~ I am aware that there are significant penalties for submitting false information, ENT AREA
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AG C DE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANA710N Ut ANY vluLAUUrva (fYererence au arracnmenrs nere~
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. _
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