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PERMITTEE NAMEIADDRESS (Include Farilirf .VamelLmw fon if Differew) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />;INFER <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ?-, <br />"A <br /> MEASUREMENT ` <br /> <br /> PERMIT <br /> REQUIREMENT i '. <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I vertd, under penalh of how that thi. document and all attachments were <br />re <br />ared under m <br />directi m or+u <br />xnickrn i <br />ord <br />e with <br />-m <br />d <br />si <br />d TELEPHONE DATE <br />"? p <br />p <br />y <br />f <br />n acc <br />anc <br />a <br />in <br />e <br />gne <br />` t . l i - ?.?''•`.. to assure that qualified persmnel properly gather and esaluatr the information - t <br />- "? submil(M. Based on my inquiry of the person or persons who manage the.voem• '-'--- <br /> or Illaw• prrs om dirm--tls m4mmsible for gathering the infornwlion, the information <br /> submilled is, to the 1-1 of my knowledgr and Wier. inre, oceurale, and corn*fe" - ? •• ? <br />• I <br />? I um aware that then arc signiraant penallit, for submitting false infornuttion SIGNATURE OF PRINCIPAL EXECUTIVE - - • ? <br />TYPED OR PRINTED . <br />Including the possihility of fine nml imprisonment for knowing ekdxeons. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANAIIUN UP- ANY VIULAIIUNS (Hererence all affachmentS here) <br />EPA Form 3320-1 (Rev. 3198) Previous editions may be used. Tltiti is A4-part form. PAGE OF