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PERMITTEE NAME/ADDRESS Ilnrladr FaciGry A'a~nr/location if lh;(/rnntl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER l cenit± umler penulu .d law that thi. documrnl and all attachments ..ern <br />a <br />~isir <br />with a s <br />st <br />e <br />a <br />ed <br />der m. di <br />ectio <br />e <br />i <br />•o <br />da <br />de <br />i <br />d TELEPHONE DATE <br /> y <br />pr <br />p <br />r <br />un <br />r <br />n <br />r wp <br />n <br />m <br />n un <br />r <br />ncr <br />em <br />s <br />gne <br /> to acwre that qualified pcr.onnel pruprrl7 gather and evaluate the information <br />- -- ----- - +ubmitl d. Raed ~~n m~ inquiet d the perwn or prrs~m. Nhn mana>!e the .rslem, <br /> or three prrwns dirrctl~ rcprnsihle for galhcring the information, the iuGrrmrtlat <br /> submitted is. to the be+t of m~ Arwwledge and belief, true, accurate. and canpkte. <br /> <br />f <br />1 <br />th <br />h <br />l <br />ifk <br />l <br />b <br />i <br />i <br />f <br />l <br />i <br />f <br />l SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED se <br />am aware <br />at t <br />en an s <br />gn <br />unt pena <br />tlcs <br />wr su <br />m <br />tt <br />ng <br />a <br />n <br />urmat <br />na. <br />itw•luding the prnsibdih of fine and imprixrnmenf fnr knowing siolatirms' OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER _ _ <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. 3199) Previous editions may be used. T~IiS iS a ~3-~BTi tt)Tm. <br />