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PERMITTEE NAME/ADDRESS ~Incftdr Fbcifuy .\'ame/I~rotion iJDiJJrrrnU <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO OAY 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 TYPE <br /> ANALrsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I «rury under penauy of Inw that this documem and nll uuachmenh were <br />nr <br />n icir <br />r <br />ar <br />m <br />di <br />tio <br />u <br />in a <br />• <br />rdo <br />with ~ <br />cte <br />d <br />i <br />d <br />d <br />d TELEPHONE DATE <br /> p <br />rp <br />un <br />er <br />y <br />rec <br />n <br />c <br />pr <br />m <br />a <br />n <br />ncr <br />y <br />m <br />gnr <br />a <br />a <br /> to azure that yunlified prrsunnd properly R•at Err and ec:duate the inrormation <br /> mhmkted. aaxd ~m me ittyuin of the perum or prraxts who munn¢e the system. <br /> nr lhu.r persrntc dlrecth mptnciltk for gathering the information, the htlormatuut <br /> cuhmiurd ic, to the hest or my knowhdgr and Itrlirr, true, acruratr. and aimpktr. <br />1 <br />h <br />i <br />if <br />l <br />i <br />f <br />h <br />i <br />i <br />r <br />i <br />i <br />l <br />lb SIGNATURE OF PRINCIPAL EXECUTIVE <br /> nm awnrr That t <br />ere are + <br />gn <br />iram pma <br />t <br />n <br />or w <br />m <br />tt <br />ng <br />n <br />cr <br />n <br />orma <br />n. AREA <br />TYPED OR PRINTED includintt for prKCihilin orfinc and imprLcunmmt for Avowing tiolntiuro. OFFICER OR AUTHORIZED AGENT DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA Form 3320-t (Rev. 3/991 Previous edtions may be used. 7'1115 iS 73 4-Pert tU1T11. <br />