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PERMfTTEE NAME/ADDRESS ilnrlade F'arititr .flame//.oration iJDi/frrtrul <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 ND, <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 _ r.. _ . •- . .- <br /> REQUIREMENT ' <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I a•nit. under penulh rd low that this docunxnt and all uttnrhmrnts wrre <br />rr <br />drr <br />o <br />ed <br />di <br />ertinn o <br />fsl <br />d <br />with <br />t <br />I <br />d <br />i <br />d TELEPHONE DATE <br /> p <br />p <br />r <br />un <br />m~ <br />r <br />r wpen <br />on <br />n xror <br />ance <br />n s <br />em <br />es <br />gne <br /> to u++urr thm yuullfied prrwnnd pmprrl} guthcr and evaluntr the Intnrmatlon <br /> .uhmitted. f4asrd nn m~ ingrain of the perum nr persons who munugr the +rstrm, <br /> ur thosr peroim~ dirrrtl~ respmsihk for gathering the informu0on, the informatkn <br /> whmitted i. to the hest :d m~ knowlydge and hrlirf, true, rrcuratr, amf complNe. <br /> <br />i um aware that Ihrrr urr si <br />nificant <br />rnolti <br />s for mhmittin <br />fals <br />information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />p <br />r <br />g <br />e <br />' <br />indnding the pn<cibititc cif fine and Impri+onmrm for knowing +iidatlons, <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA Form 3320-~ (Rev. 3199) Previous editions may be used. '-'~ ] TFtis is a 4-part form. <br />