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PERMITTEE NAMEIADDRESS (Include Farifitp Name l reran. n if ifi ferenr) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />D' I NEEF? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />Mir <br />F - <br />t, HF <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANakrsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT I <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I - - C?;?=1 <br /> PERMIT .•..:.. _ <br /> REQUIREMENT <br /> SAMPLE <br />S <br /> MEA <br />UREMENT <br /> PERMIT : , • n 1141• r: 7t- - T .:: - ' <br /> REQUIREMENT <br /> SAMPLE t <br /> MEASUREMENT Imo ? LiZ?? <br /> PERMIT a <br /> REQUIREMENT : ," af?fftitJ <br /> SAMPLE <br />f r/ <br />! <br />Z R <br /> MEASUREMENT _ I `jI <br /> PERMIT 3RFU - <br /> REQUIREMENT Af'ti? iA <br /> SAMPLE <br />MEASUREMENT r <br /> PERMIT <br /> REQUIREMENT y r ; <br /> SAMPLE I??? ` l? Zn <br /> <br />MEASUREMENT <br />/J z0 <br />1 <br />1 <br />V <br /> PERMIT r r; - <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I rerun under penalty of [am that th6 document and an atlachment+wert' <br />r <br />d <br />ti <br />i <br />d <br />d <br />di <br />h <br />i <br />c <br />i <br />h <br />t <br />d <br />i <br />d _ <br />i - - - TELEPHONE DATE <br />7-- l 1 prepa <br />un <br />er my <br />ree <br />on ar suprn <br />e <br />s <br />m <br />n a <br />cor <br />ance w <br />t <br />a - <br />rm <br />e+ <br />gm <br />m aswre that qualified personnel pruperit gather and es Imle the informatom <br />submitted <br />Based on m <br />inquin of the <br />e-n or <br />rrs;ms who mana <br />e the s <br />st <br />m <br /> . <br />p <br />p <br />g <br />y <br />. <br />e <br />7 <br />t or nose person, direrib responsible for rwt6ering the information, the information _ <br />, <br /> +ubmitted i,• to the hest td m) krwrwledge and belle(. true, accurate. and complelr. <br />j <br />' <br /> am aware that there are significant pemdtio for submitting fare information. SIGNATURE OF PRINCIPAL EXECUTIVE -- - <br />t <br />' " <br />/ C' '" L/ `? V f ? <br />OR PRINTED in <br />l <br />di <br />th <br />sibilih <br />f fi <br />t r <br />d i <br />i <br />k <br />i <br />hd <br />i OFFICER OR AUTHORIZED AGENT R <br />TYPED c <br />u <br />ng <br />e po <br />ne an <br />mpr <br />wmmen <br />o <br />or <br />now <br />ng s <br />nt <br />ons. ODE NUMBER YEAR MQ DAY <br />ANN) t1LF'LAIYA 1 IU1Y Ur ANT Y <br />(nererence are arracnmenrs nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This W;1 4-part fo mi.