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PERMITTEE NAME/ADDRESS +Inrfudr Farifi» h'asdlrxation i~CAfJrnnr <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 />pM8 No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N~, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER ~ ,~rul~ under penalty of law that mi. A~runxnt and all allachmrnLS Here <br />i <br />d TELEPHONE DATE <br /> prrparnl under ms dim•tiixt or +ugrsicirot in acrnrdance with a gstem drx <br />gne _ _ <br /> to assurt that qualified personnel proq•r1~ gather uttd evahwte thr informmtion <br /> submtttad. fta+ed on ms inyuln of the perwn or persons who manage the system. <br /> ur those pera~uts dirrcth resgmsiAle fur gathering the information. the information <br /> submiltrd is. to the Rest of my knowleAge and belief, true, accurate, and cumplrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that them are significant pennldes for submitting false information. <br />FFI <br />RI <br />R <br />A <br />TH <br />AGENT AREA <br />• TYPED QR PRINTED including the pussibilin to fine and imprisonment for knowing vitAatkms, CE <br />OR <br />U <br />O <br />ZED <br />O DE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />PAGE OF <br />EPA Form 3320-1 (Rev. 3199} Previous editions may be used. ~I711t IS <l ~-111I[ 1.OiRl. <br />