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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 />OFFICER I certif
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<br />y under penalty of law [hat [his document and all attachments were TELEPHONE
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<br />DATE
<br />NAMElTITLE PRINCIPAL EXEC prepared under my direction or supervision in accordance with a system designed
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<br />~~„~.~ to assure that qualified personnel properly gather and evaluate the information
<br />submitted. Based on my inquiry of the person or persons who manage [he system,
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE ~ ~~ ~~
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<br />i'' 1a I am aware that there are significant penalties for submitting false information, OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY
<br />TYPED OR PRINTED including the possibility of tine and imprisonment for knowing violations. CODE
<br />COMMENTS AND EXPLANATION fJt ANY vluLw l wrva (neterencr nn aua~.n...c.[aa ..`.~i
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<br />Form 3320-1 (Rev. 3/99) Previous editions may be used.
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