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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<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
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION
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<br /> REOUIRENkENT
<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed ,
<br /> to assure [hat qualified personnel properly gather and evaluate the information ~
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<br />~.~'"~"~ ,~.. submitted. Based on my inquiry of the person or persons who manage the system, ~ ~ (((
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ~~~ `~`~ ~^' ~~ O~ ~ ~~
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<br />.? I am aware that there are significant penalties for submitting false information, AREA
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. t"1C%=i~ti1~6,~45~iS-S=a~4=~3Ct`~O'Ilri. PAGE ~OF
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