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PERMITTEE NAMElADORESS tlnrftrd~ furilitr.~'antdl.~xvuion if UifJ'rrrnri NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION 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, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> pNALYSiS <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/TITLE PRINCIPAL EXECUTIVE OFFICER { cenit~ under prnriq of law that thi+dtrument and all attarhmrnt+ srrn <br />d <br />d <br />di <br />• <br />i <br />• <br />i <br />i <br />i <br />d <br />ith <br />~ <br />d <br />i <br />d TELEPHONE DATE <br /> un or supa <br />ancr w <br />a .~ <br />+trm <br />rs <br />~ns <br />prepare <br />un <br />er m~ <br />m <br />t <br />n <br />s <br />on <br />n aaror - -- - <br /> to assurr thal qualified prnonnel prnprrl~ Qathrr and es oluate the information <br />. _ - whmitted. Bs.ed ~m nn inyuin of the p<•r+on ~r penonc .. ho mamgtr IM• +)Strm. <br /> nr lhnse pe~nas direrdc rr+poaible for RathrrinR the information. the information - <br /> submitted is, m the hest of m~ krroaled>;e and M•Ikf. True, arrurate, and enmplcte. <br />h <br />{ <br />h <br />b <br />i <br />l <br />fi <br />I <br />Ih <br />ifk <br />lti <br />i <br />f <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE '` <br /> <br />TYPED OR PRINTED am uaarr <br />rre arr . <br />,r .u <br />n1 t <br />en <br />ant pena <br />. <br />m <br />tt <br />nK <br />a <br />se <br />n <br />orma <br />on. <br />inchidink the I~...ahdit...t fine and impri+unmrnt far knos.in>: ciotuti~mn. <br />OFFICER OR AUTHORIZED AGENT AREA <br />C DE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(r-tererence ail anacnmenrs Here) <br />EPA Form 3320-t (Rev. 3199) Previous edtions may be used. This 1S ~ 4-~OTt 1ort11. PAGE OF <br />