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PERMITTEE NAME/ADDRESS Ilnrludr Farilur A'omr/L~raian if IkfJorntl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <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 />OFAB N0. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ- FREQUENCY <br />OF SAMPLE <br /> EX 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(fITLE PRINCIPAL EXECUTIVE OFFICER I ceAif> under prnulh of law lhnl thi+dnrument um1 all atWChmruU »erc <br />s di <br />ti <br />with <br />y <br />t <br />d <br />si <br />d <br />d <br />l <br />i <br />i <br />i <br />d TELEPHONE DATE <br /> ud <br />rr m <br />rec <br />on ~K wpen <br />n accor <br />ance <br />em <br />e <br />gne <br />prcpurc <br />~ <br />nn <br />a + <br />+ <br /> to mwrc that yuulifiad prrwnnd properly gather and esalualr for information <br /> suhmittrd. Raxal an m~ inyuin of the perww or penuas who manage the +~-ctem. <br />_ _ or those p<•r~ntu directly reapun+ible for gnlhering the infarmutwn- the informuifnn <br /> owl <br />s <br />h <br />iu <br />e h <br />t <br />th <br />h <br />.t <br />f <br />k <br />d <br />e <br />d b <br />li <br />4 t <br />e <br />t <br />d <br />o <br />l <br />te <br /> <br />' u <br />m <br />r <br />, <br />o <br />e <br />c <br />o <br />m. <br />n <br />e <br />g <br />an <br />r <br />r <br />ru <br />- accura <br />e, an <br />c <br />mp <br />e <br />. <br />• <br />l SIGNATURE OF PRINCIPAL EXECUTIVE ~ ` <br /> <br />TYPED OR PRINTED I am uw are that there arc signlfn <br />ant petwltir+ for submitting fa <br />+r infnrmatinn, <br />im hiding the pwnibilitr of fine and impri+.mmenl fur knowing vi,dationti <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reterence all attachments Here) <br />EPA Form 3320.1 (Rev. 3t99) Previous editions may be used. Th;s is a 4-pan form. <br />