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PERMITTEE NAME/ADDRESS ilnrlude Fnrilih \bntr!l~rr~rrtrrn if Differenrl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCNARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR M DAY <br />LOCATION FROM TO <br />Farm Approved. <br />oraa No. 204o-oooa <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX ALYSIS TYPE <br /> AN <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , -~ <br /> REQUIREMENT <br /> <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 /> <br />REQUIREMENT _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REMENT <br /> REQUI <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - . , i .. .. t <br /> REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrrtih order pcnalh of law that Ihls drK•umcm amt all attachments sere TELEPHONE DATE <br /> prepared undrr ms direction or supcnision in arrordance with a +V SICm dreignad <br /> to aswre thot yualifieJ prrsonnrl praq•rir gather anA esaluate the information <br /> +ubmittcd. Rasnl on my inquiry of the percnn or person who manage Ihr +. stem. <br />or those perwm dinetly rccpnnsible for gathering thr informalkm. the information , <br />- t <br />let <br />i <br />d <br />d t <br />•Ikf <br />d <br /> r. an <br />comp <br />e- <br />whmitud is, to the best of my Anow <br />e <br />ge an <br />w <br />. Iruc. arcura <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> I am aware that them are signifkam penalties for wbmitting false informadtm. AREA <br />TYPED OR PRINTED including the pm+ibility.d fine and imprisrmmcm for lnowtng+iulatlons. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attacnmenrs ~erel <br />FPA Fonn 3320-1 (Rev. 3199) Previous editions may be used. TIIiC 1S ~1 4-pdi'i'~OTITI. PAGE OF <br />