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PERMITTEE NAMEiADDRESS !include Fnciliq• Nnmr•Zuturiat jDlp~tu <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 /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LAADING QUALJTY OR CONCENTRATION NO, FREQUENCY <br />Of SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE • <br />~; MEASUREMENT <br /> PERMIT r' - ~}'.7 ,- . r <br />'' REQUIREMENT ~ ~~' <br />,. SAMPLE <br />~ MEASUREMENT <br /> PERMIT ,. #; ~• t' .. I r ;; •Yc t!•dri:• s:- ; fr ~ sri-. , . ~ .. , ~ ~-;,.~ <br />- r' 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 /> <br /> PERMIT <br /> REQUIREMENT <br />NAMElriTLE PRINCIPAL EXECUTIVE OFFICER I certify under pen.ilty of lea thm thu dixun+ent and all attarhrncnM were TELEPHONE DATE <br /> Prepared under my direction ur suprn•ision +n accotdnnce with n system designed <br />r to a~surc that yualif+cd pcnonnel properly gather and rvalunic the +nformation <br />_ <br />, <br />': ~ c. >"' ~ - subtnincd. Rasesi on my inquiry of the person or persons wha mnnnge the systcrn. r~ . _- --'"T <br />_ _ .r--~ - <br /> the informnuon <br />casiblc fix gathering the information <br />or those persons directly res ~ ~ - <br />'~ ~ <br />' , <br />p <br />wbmittcd ia. to the best of my knowledge and lxlirf. tnre, occutnte. and cottiplctc SIGNATURE`OF PRINCIPAL EXECUTIVE ~ y- <br />' I um aw+vc that there nrr significant pcnnlties for submitting false in(+rrtnation, OFFIGER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />Mb <br />DAY <br />TYPED OR PRINTED including the pus~iMbty of fine and in+pnsnnment for knowing vialnuon . CODE <br />COMMtNI, AIVU t1CYLAIVAI IVrV Vr AIVT VIVLHI IVI\J 117CICICII6Q on anawunmua ncrc~ <br />_DURE. REP <br />EPA Form 3320-1 (Rev. 3/99) Previous tuitions may be used. <br />BTATSSTICAL PDIS~T ES? <br />RT FORM TD DMR. <br />Ti~i515 a ~-part S~~n,. PAGE OF <br />