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PERMITTEE NAME!ADDRESS ,-:...::: i :::;,~, . , ~, , ;,,~-,.,,.,,:, NATIONAL POLLUTANT OISCMARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />pMB No. 2040-0004 <br />F - F 1 i`~Ai_ <br />f3P~ ~EIi1 Pr_~i•~i:, f0 RCl <br />X <br />NOTE: Read Instructions before comoletina this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />} PERMIT . , ~ ~;:_ <br />• r c= ; !j 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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I comfy under pcnaln of law that this document and alt sttaehmem..ccrc <br />d <br />d <br />~ d <br />i <br />i <br />~ <br />~ TELEPHONE DATE <br />_ <br />~ ~ - <br />5~~~ <br />s <br />~ S <br />~ er m} <br />prepare <br />un <br />uect <br />on or zupen <br />tston <br />n accordance ~~ <br />ittt a cyst.m dcaKned <br />w as~tue that qualJictl prttiunncl properly gather and evaluate the intnrmation <br />__ <br />~, <br />•: ~ <br />` submitted. Haied un m} in airy of the enon or <br />q p prr.txts who manage the Jystern. - <br />7-` <br />~ tv thane perxwns directly respoasihle for gathering the in&xmadan, ffic mfnrmation <br />C_"• ! ~ i ~ " ~/ submtttcd is, to thz F+est of my know Iedt:c mtd heltcf, true. a.cuntc, and comn(ete <br />I :un <br />roarc that there arr <br />mti <br />fluc, t~ <br />~r <br />uhmBune ' ~h <br />im f4n <br />• : <br />t <br />-. <br />u~:r SIGNATURE OF PRINCIPAL EXECUTIVE - .~ ,: ' - - <br />' / % y <br />TYPED OR'PRINTED ag <br />. <br />~ <br />. <br />o <br />. <br />s <br />n <br />~ <br />rn: <br />a <br />ncn~:ime the povs!hiltty of Gnc .!nrt ~nran, nvnrm for l.rn~.~iti , i.~! ~:~rt" OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />GUMMEN Is Anv rxrwnAl Ion ur Anr vwL.AI Ions frrererence au artacnmenrs nere~ <br />:4 <br />t •J <br />EPA Form 3320-1 (Rev. 3199) Previous eddions may be used. ~~}tJS IS a $-part ~Oflll. PAGE OF <br />