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PERMITTEE NAME/ADDRESS ilnrludr farid'n ~umr~(•vatinn iJl>ifJrrrMl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FaclLlTr 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, <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT I <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 certify under prnalh of Inw that this document and all atwchmrnt. were <br />ctio <br />u <br />cr with <br />s <br />ac <br />•si <br />n <br />e <br />a <br />d u <br />d <br />di <br />o <br />s <br />x• <br />i <br />io <br />i <br />a <br />da <br />d <br />d TELEPHONE DATE <br /> ~ <br />pr <br />p <br />re <br />n <br />rr my <br />re <br />n <br />r <br />ul <br />n <br />. <br />n <br />u <br />cc <br />r <br />n <br />a <br />m <br />. <br />r <br />R <br /> tr. a+sare thnt qualified pero~mnrl pr~yrrrir gather untl e~ahmte the information <br /> sulwnittrd. Bused nn m~ inyuirs of the prr..nt or pcn~xts who ntnnagr the syacm. _ _ <br /> <br />or [hose prnnm dirrclly responsiMe Gtr galhrring the informatitm, the information ~ <br /> submitted is. to the best of m. Anowlydge and Ixlir(. trnr, uccuratr, and complete. <br />if <br />lli <br />itti <br />ti <br />I <br />th <br />t <br />l <br />• <br />i <br />f <br />b <br />f <br />l <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED atn aware <br />~ <br />ng <br />se <br />orma <br />on. <br />a <br />t <br />w <br />re arc s <br />gn <br />icant pma <br />or w <br />m <br />a <br />n <br />including the possibility u( fine rend Impr'rsonmrm for Lnowing cudmir,m, <br />OFFICER Ofl AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. 3199) Previous editions may be used This 15 3 ~-~i3I'i fUf111. PAGE OF <br />