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PERMITTEE NAME/ADDRESS Undudr F'acilitY .Vrtmdtsaation iJlhJfrrrnt} <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 20x0-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, 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 /> 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 l certih under prnnlN otla» thm thi, documrnt and all auachmeoB »ere <br />nn•o <br />r <br />d <br />der <br />di <br />ti, <br />o <br />r <br />icin <br />i <br />dan <br />e »ilh a + <br />lem d <br />+i <br />d TELEPHONE DATE <br /> preya <br />e <br />un <br />tm <br />rec <br />m <br />r wp <br />n <br />n <br />n <br />r <br />c <br />w <br />r_ <br />~ne --- -- --- -' -~ - <br />_ to acsurr that yualiMd prrxmnel properly Rather and r+almte the infnrniution <br />- - - - submttlad. Baud on my Inyuin or the prrum nr prru,nc whu manage the c++tem. <br /> or those persons directly rrsponciMe for gathering the infurnwUon, the infornwtion <br /> <br />~ ,ubmitted ic. In the t,rsf of my wnnwkdRe and belief. true, accurate, xnd n~mplrte. <br />th <br />f <br />r <br />b <br />I <br />m <br />» <br />t th <br />si <br />ifi <br />t <br />ltir <br />it[i <br />r <br />lsr i <br />l <br />rnr ti <br />m <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> a <br />a <br />arr <br />a <br />ere are <br />gn <br />can <br />pena <br />. <br />o <br />,u <br />ng <br />a <br />n <br />o <br />i <br />. <br />m <br />OFFICER OR AUTHORIZED AGENT AREA <br />• TYPED Off PRINTED including thr ptxsibility of One and impriv,nm,vu far Ann»inR ciidalions. l CODE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference aJl attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous ediUOns may be used. TI1IS IS a ~-pdTt fOitll. PAGE OF <br />