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PERMIITEE NAMElADDRESS rlncluda Forility:\'amdLocatian if UtJJrrrert NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILm _ i.: i, :~ O; MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO D Y <br />~~N FROM TO <br />Y ftiRD~ RPti .. <br />Form Approved. <br />OMB No. 2040-0004 <br />• <br />NOTE: Read Instructions before comoletina this form. <br />PARAMETER pUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE t <br /> MEASUREMENT / ~ <br />I ~" U <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT - <br /> . <br /> PERMIT ~' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~ <br /> PERMIT - .t . <br /> REQUIREMENT - <br /> SAMPLE <br /> <br />MEASUREMENT _ <br />I <br /> <br /> PERMIT ~ <br /> REQUIREMENT <br />• SAMPLE _ - <br />i <br /> MEASUREMENT - - .~ <br /> PERMIT -~ .. .. _ , - . , <br /> REQUIREMENT <br /> SAMPLE ~ - <br /> MEASUREMENT r <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />M <br />REMENT <br />AS <br />~ i .( J ~ <br />1 ~ <br />~• ~ <br /> E <br />U <br /> PERMIT - _ ~ • - <br /> REQUIREMENT _ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER t ,. ~t~r, under penalh of law thnt this dnvment and all nttachtneme were <br />d <br />d <br />di <br />l <br />• <br />• TELEPHONE DATE <br /> prepare <br />un <br />er nn <br />rnt <br />on or cupeni.ion in ;K <br />curdancc with a .~~trm dr.iKned <br /> to tnwrr that qualified personnel prv,perl~ ><athrr and e~aluutc ihr information <br /> wbmNtid. Bard on m. inyuin- or the person ur pervon. who manal<c IM rydem. <br /> or th,ne persons dircclla re+ponsiblc for katherinR the information. the information <br /> suhmitnYl is. to the best nr m. knowied>,.c and hdirf, true, uccuratr, and complete ~ <br /> <br />I am uw are that there are si~ni0cunt <br />ennitie. for submFttin <br />n <br />r <br />i <br />fo <br />tio $IGNAT E OF PRINCIPAL EXECUTIVE - 1 <br /> <br />TYPED OR PRINTED p <br />A <br />u <br />e <br />n <br />rma <br />n. <br />includint; the possihilits of fine and imprisanmrm for AnowinR ~inlutnms, <br />OFFICER OR AUTHORRED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />.. _......_..._...._ _... ~_......_.. _. ~... .._v..._.. ,. _._._...,..........~...,...,....~.....~, ~_EO TU RE{3UEST A REASONAI~LE °QTI:NTIAI_ ANALYSIS 3~ <br />~,~;•L,.- PAGE OF <br />EPA Form 3320-1 (Rev. 3,'99) Previous editions may be used. - ~I'IIIS iti 8 4-PkTr~OfTil. <br />