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Form Approved. <br />PERMIITEE NAME/ADDRESS llnrlude Farililr .dam<ilaration if I>rfJrrrnrl NATIONAL POLLUTANT DISCHAgGE ELIMINATION SYSTEM ((NPDESJ pM6 NO. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER SL- ~Ec <br />FACILITY <br />LOCATION <br />MONITORING PERIOD <br />YEAR MO OAY YEAR MO DAY <br />FROM TO <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 /> 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/TITLE PRINCIPAL EXECUTIVE OFFICER 1 rertif~ under prtWh Uf IYw that thi+d~Kn111C01 and :dl attaehmrnB wrre <br />n <br />urrd under m <br />dim•tion or +u <br />crvi+ion fn aca•urd:mre with o . <br />oem de.i <br />;nrd TELEPHONE DATE <br /> p <br />p <br />~ <br />p <br />p <br />> <br /> In aswrr thYt yuYlitird perwmrl proprrlp ~mlhrr and rerltmtr thr information <br /> snhmiuad. BaaA un mr inyuin of thr prrwm or prrwns whn mannte the scctem. _ <br /> or thiw• prnon+ dirrcll~ rasq,n+ihlr Gar ¢Ylhrring the informalGm, the information <br /> whmitt d is, to the best nt m. knowledYe and beikt, true, accurnte, and complete. <br />I Ym aware that Ilw•~r Yrr +i <br />nifiaunl <br />a•nYlli~y for mhmiuin <br />ful+e• inl~.nnati~m SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED p <br />g <br />, <br />g <br />indudin>( Ihr iwhsihiliq o(finr and impriaonmanl fnr Aro~winy .inlati~~m. OFFICER OR AUTHORIZED AGENT AREA <br />D NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,`99) Previous editions may be used. i.%745_ •I'his is a4-pan form. <br />