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PERMITTEE NAME/ADDRESS llnrludr Pari6ry.~atltdlaration if DrfJirentl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCA71ptr <br />NATIONAL POLLUTANT DISCHAAGE 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 />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <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 I certif. undo penalq Iron.. that tht~ docvmrnt and all uttachmenl+ were <br />d <br />l <br />dl <br />• <br />i <br />i <br />d <br />ith <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> <br />- um <br />er m~ <br />reclion ur w(D <br />n» <br />on <br />n :wror <br />anre w <br />a +~s <br />em <br />e <br />gne <br />Prepare <br />to •u lire lhal gUDllrud personMl prr.perls gather nlld esaluale the informalial <br />cuhmittrd. l3u+cd nn ms inquir+ of the perxrn Dr pcrwn+ w hu manage the +~+4•m. <br />ur thlrsa• Persons dircrd~ respnndMe fur gathering the information, the infornaton - . _ <br /> submitted k. to for bM of m~ knowledge and belief. true, Decorate. and complete. <br />i <br />1 <br />l <br />i <br />l <br />• <br />f <br />h <br />i <br />f <br />1 <br />• <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED t}a <br />~nn.rl <br />~~n, <br />am aware Ihat t <br />nrc are +ign <br />rlcant pena <br />+ <br />or w <br />tting <br />D <br />+I <br />in <br />m <br />inchdinp, the pussihilite Irf fine Dnd impr6onmem for knnwing +ioLuiin„. <br />OFFICER OR AUTHORIZED AGENT AREA <br />C DE NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/9J) Previous ed+tions may be used. This is a 4-P~>•t fornl. <br />