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PERMITTEE NAME/ADDRESS Include facilin•.Name~Yircattnn tjDifjerenr) <br />NAME <br />ADDRESS <br />FacaITY <br />LOCATION... ~} <br />i:.Ft <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 />>E <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />7Q : - is - ~ r,. MEASUREMENT <br /> PERMIT ~ ~• r. ~, i. : i ; r, ;~: <br />'" '•= ~ "; REQUIREMENT <br /> SAMPLE <br />Q"~:: _ ,~., - MEASUREMENT <br /> PERMIT -. s: r ~: _ ~, <br />,_ F.~ L V: .' ". REQUIREMENT ~ ~ • <br /> SAMPLE " <br />t •; _ MEASUREMENT <br /> PERMIT - _ I: ..:. u s ,~ ,. - r t^= <br />_'r REQUIREMENT •r-.i_' - ' <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 I .cnify under Ix•nnin ut law that this dfxument and all atmchmcmts were TELEPHONE DATE <br /> rcepared tmdcr my ductuon nr supen~icion in nccurdancc with a sys,cm dcstgncd <br />~~- <br /> <br />Sl f <br />1f / <br />~ _ .~~ n:sure that qualified personnel property gather and evaluate the infiinnntaxt <br />of the person or persons whu rnanrge the sys4m <br />w <br />itt <br />i B <br />ud un m <br />tn <br />b y._~-~'~ <br />' <br />/~ ~ -t!j <br />~ ~~" <br />> <br />% ~ ~ _ . <br />~ <br />a <br />y <br />g <br />ry <br />w <br />m <br />nr thox pcnom directly responsible frn gathcrinG Ute infomutian, the informatwn •'~ <br />r subnutted rs, to the hest of my know4aigc and hcliei: true, accurate, and crnnplete. SIGNATURE OF PRINCIPAL EXECUTIVE -~ ~. ~- '1 '~ ~ <br /> 1 am aware that there are significant pettaltin for cuhmmmg false in&ttntotion. OFFICER OR AUTHORIZED AGENT AAEA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the possihiliry of fine and nupnsunmrnt for knowing violations CODE <br />COMMENTS AND EXPLANATION OF ANY <br />fHererence an aaacnmenrs Here/ <br />- This is a -~-{part f+~rm <br />EpA Form 3320-1 (Rev. 3/99) Previous editwns may be used. PAGE O~ <br />