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i PERMI7TEE NAMEIADDRESS Ilndadt FuiGtr Abatdlorafian if Dt]Jerentt <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 />=i - FROM TO <br />P E' <br />Form Approved. <br />oMa No. 204o-pDD4 <br />t ill <br /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />' <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 />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I certih under prnsJty of Inw Ihul thisd~~cumenl and all nllachrorntc were <br />A <br />d <br />~ TELEPHONE DATE <br /> ryrrparr <br />w <br />rr nn direclioo or wprni. ion in urcordarn <br />r wilh n ~ystrm designed <br /> to acwre thel qualified perwnnel rynlprrl~ ttnlher and esnlunte Ihr InformatHUl . <br /> suhmllted. Raced ~m mr inqutn tlf the prr.nn or persons whn manny}' the syctrm. <br /> nr those ryrtumc dirrrth mgal+ihk for KathcrinR the information. the informntllm <br />_, <br />- cubmiltcd ic, to Ihr bey of m~ Anuwladgr and belief, trot, accurate, and cnmpkte. <br />1 am aware that Iherr are si <br />nifi <br />ant <br />ltio fo <br />uhmhli <br />f <br />l <br />i <br />t <br />l <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />TYPED OR PRINTED <br />r.~uur uTn ...... g <br />c <br />ryrna <br />r s <br />n~ <br />a <br />n <br />ormat <br />se <br />oa. <br />itlduding Ihr Ic<ibilit~ of fine and im nNromrnt far knowin>; riedntiaws. <br />.~....... ... p_.. p OFFICER OR AUTHORIZED AGENT C~EA NUMBER YEAR MO DAY <br />._ <br />s.vn~nea_~\ e v n~•v GAr-LMI\M I IVI\ Vr MI\ <br />EPA Form 332x1 (Rev. 319sj Previous editions may be used. <br />nn auncnrnenrs Here/ <br />Tfiis is a 4-part forn~. <br />