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PERMITTEE NAME/ADDRESS (Include FacUUy.VamrAoratian off DiJ/rrentl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />'f <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 />(51 <br />F ' <br />CiIt <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certir, under pemdq of law that thi• docamem and all aaachnienn were <br />d <br />d <br />di <br />• <br />w <br />i <br />d <br />i <br />h <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> Uon or suprr% <br />n accor <br />ance w <br />a ry <br />prepan <br />un <br />er mI <br />m <br />on <br />t <br />em <br />es <br />gne <br /> to &? re that yualiried personnel Properly gather and esaluate the information - <br /> submitted. Based nn my Inyuirs of the pre m or We a% who manage the system, <br /> or those persons direrti, resprmsilAk for gathering the information. the information <br /> itt <br />to th <br />h <br />t ar <br />k <br />d R <br />li <br />rat <br />a <br />d <br />let <br />b <br />d k <br />d <br />f <br />t <br />-l <br /> <br />' , <br />w <br />m <br />e <br />e <br />my <br />m <br />e <br />ge an <br />e <br />, <br />rue, accu <br />e. <br />comp <br />e. <br />e <br />e <br />n <br />I <br />th <br />th <br />i <br />if <br />d <br />i <br />f <br />h <br />it <br />i <br />f <br />l <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />TYPED OR PRINTED on, <br />ant aware <br />at <br />ere are s <br />gn <br />icant prm <br />l <br />es <br />or su <br />m <br />t <br />ng <br />a <br />se <br />n <br />orma <br />Including The Possibility or floe and imprisonment ror knowing ciolntlons. <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />SUBMIT <br />EPA Form 3320.1 (Rev. 3/99) Previous ediions may be used. ?2(i This is a 4-part form.