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NAME <br />ADDRESS <br />llnrludr Forilily .Yaae/lnralian if -hffornf l <br />FACIUTv <br />LOCATION , <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONCt-ORING 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 N0. FREQUENCY <br />OF SAMPLE <br /> EX S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSI <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ _ '- - <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ t, <br />( <br /> REQUIREMENT _ <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br /> REQUIREMENT <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certifi under pcnahl of Ixw thxt this d«umenl amt ull utWChments were TELEPHONE DATE <br />prepared under m~ directiwn ta- supra ision in accordnnrr wilh a s~aYCytt designed <br />to acsurc that ytuliRed pervrnneJ prnprrly gxther and esnluate the infnrmatian - <br />whmilled. Based nn nq inyniry of thr prrson or perwns who manage the ±~.tem, <br />- or those perm dircctl~ roptmsihk for gathering the inf ~rmxlion. Ihr informatlun <br />k <br />' <br />te. <br />whmltted is. In Ihr Ixct of ms knowledge and Ixlief, true, acrnrale, and romp <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 em aware That Iherc arc significant penaltiaY for wbmilting false information. AREA <br /> .i~~lations <br />d im <br />risnnmrnt fur krxtwin <br />th <br />w <br />ihilih of f <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MQ DAY <br />TYPED OR PRINTED p <br />g <br />. <br />nc <br />e { <br />ns <br />ine an <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANr <br />(rYererence an arracnmenrs nere~ <br />EPA Form 3320-1 (Rev. 3199) Previous editicros may be used. T}lic is a 4-(1:iFt fOTn <br />