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PERM(TTEE NAMElADDRESS ilnrltufr Facifir~ .1'umrlLxution iJ DiJJ`oeN1 <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 />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />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 /> PEAMIT . < ., <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PEAMIT ~ _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cutiQ undrr pemlt} of law that thi+d«timem and all attuchmrnts were <br />d TELEPHONE DATE <br /> prrparrd undrr my dinrtimt or wpeni+ion in accordance witlt a system dngtna <br /> to a sort that yuulifird prrsonnrl prnprriy gather rnd rvnhwtr tl>e infurntatx~a <br /> submitted. Bawd nn m~ inyuin of dtr prnun ur perwns who manngr thr srclrm. _ <br /> nr th.nr prnuns dirrctl~ resp.roihk fur gathering the infurma6on. the infurtmti~m ' <br /> whmitted is, to Wr !)rst of my Anow {edgy and belie(. Into, aacuratr. and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I um awarr that thrrr an• signifia-ant prnulties for submitting false information. <br />including the pussibibt~ of fm<and imprisonment fur Avowing sintatiom_ <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 31991 Previous editions may be use• <br />Phis is a 4-part form. PACE of <br />