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C H7.i;7 i EE PdAME ADDRESS •. <br />t:AfdE <br />ADDRESS <br />FACILITY <br />LOCATION. <br /> <br />I~eaaacr ~ <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 NO, FREDUENCY <br />OF SAMPLE <br /> ~ TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />1I MEASUREMENT <br />''° PERMIT .. .. <br />_ <br />~ <br />i <br />, <br />- <br />J ~ + <br />~ REQUIREMENT ,.:' ;P'~ <br />~ '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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/'f1TLE PRINCIPAL EXECUTIVE OFFICER I certify under penaltq .d law that this daument anJ all anachrncnts were TELEPHONE DATE <br /> prcpttred under my direction or supervision in accordance with a system designed <br />- <br />' <br />N ~ <br />S cu acsurc that yualificd pcrsottnel properly gather and es~aluate [he inf'wmatim - <br />- - <br />t . , <br />; <br />< o submitted liax'd un my inquiry of the person or pcr::ons who rIVImIgC IhC Sy111•In~ _ __ <br />- <br />~ ~ ~ ~ -. <br />` <br />-- <br /> or those persons dtrecth• responsible fur gathcnog the information, the inlurmatiwt ~ <br />.' ~ <br />- <br />~ <br />' submitted ts <br />to the best of my knowled <br />e and belief <br />true accurate and rnmplctie ~ <br />; r i - <br />, <br />g <br />. <br />i <br />h <br />h <br />il <br />l <br />i <br />I <br />i <br />k SIGNATURE OF PRINCIPAL EXECUTIVE .,( - ~ <br /> <br />TYPED OR PRINTED icant pena <br />t <br />es for submitt <br />rrtnm:,n <br />I am aware t <br />at t <br />ere arc siEm <br />ng <br />nlse <br />n <br />mrluJmk the txxsibitity of tine and impriwnmrnt for knowing violatiuit` OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />GUMMCIY I J /iPlU CAY LAtYAI IVtY Vr Mt7 r nvt.r+t tvt~a Iner er e:nce an auas;rnrrcnra ncre~ <br />~'IF2 PR~C I? EVENT' - SEE <br />:kMPL.ING INSTRUCTIOh.ES <br />EPA Form 3320-1 (Rev. 3/99) Previous editioru may be used. <br />3. FOR REC3UIFtEMEP <br />'G. 1.4. <br />?,"I'i~i5 i~,:~ 4;parE form. <br />