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PERMITTEE NAMElADDRESS tlncfude Farifiry ~ti'anta/l.uearinn iJfliJJerrnrl <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 ALYSIS TYPE <br /> AN <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 't`"F <br /> '~'~ `L <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> T <br /> REQUIREMEN <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certi!) under petutlh of law that this document and all attachments were TELEPHONE DATE <br /> prepared under m. direction or +uprn isiott in accordance with a +y stem designed <br /> In nwre that yuulifn•[I perwmnai prnperl~ pother a~ rsaluatr tM• information <br /> +ubmittcd. Ra+cd on m) inyuir+ o! the pervm nr peMms who manage thr +>'stem. <br /> rtwns dirrdl~ rnpnnsiMe for >;nthering the information. the inlormathm <br />or th~nr <br /> p <br />d <br />kt ? ~ <br />. cwmp <br />r. <br />+uhmitted i+, to ihr brst .d my knuwiedge and belief, trur. nccuratr, an SIGNATURE OF PRINCIPAL EXECUTIVE <br />" I am aware that thcrc are sign~rvnt lKnalties tar sabmiUing fuhe information. AREA <br /> owi <br />+inlatiom <br />i <br />trnrk <br />rf <br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />+onmen <br />n <br />ng <br />imiudingthepo+vbiliq u <br />inean <br />mpr <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attacnmenrs Here) <br />FPA Form 3320.1 IRe~o~ 3ci:~~ r-..:n~;u=. <. ~•av be ,~s;-~f i!n~ t~ ,~ <br />