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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifD~erent)
<br />NAME ,;
<br />ADDRESS L._i~r_~~.t,.~~ ~•~'•~ ~`~ihEi{C::C•'s ~1.i.~;~~.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDE$)
<br />DISCHARG~~yrE MONITORING REPORT (DMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />LOCATION YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE. Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE
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<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTI E FFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br />,~` ~ ` ~ 0 prepared under my direction or supervision in accordance with a system designed
<br />to assure [hat qualified personnel properly gather and evaluate [he information
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<br /> submitted. Based on my inquiry of the person or persons who manage the system,
<br />or those persons directly responsible For gathering the information, the information f~,~
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<br />submitted is, to the best of my knowledge and belief, true, accwate, and complete.
<br />I am aware that there are si
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<br />enalties for submittin
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<br />including the possibility of fine and imprisonment for knowing violations QFFICER OR AUTHORIZED AGENT AREA
<br />NUMBER
<br />YEAR
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<br />DAY
<br /> . CODE
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. f ~'h' PAGE
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