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PERMITTEE NAME/ADDRESS (Include Facility Name/location iJDifJerent) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 />.x <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT t t () I, <br /> PERMIT <br /> REQUIREMENT F?t'?f?i'-Ili - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />r l (F <br />r(? _ <br />i?i l `_ C <br />l r' C? <br /> MEASUREMENT <br /> PERMIT s• t ,. , t x:. r - , f r.• <br />- <br />17 AT <br /> REQUIREMENT <br /> SAMPLE <br />?? <br />DJt ?? <br />?'?R, Jr <br /> MEASUREMENT <br /> PERMIT ?77POFl'- <br /> REQUIREMENT <br /> SAMPLE <br />?? ?? <br />N <br />I ?? <br />h <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I verlif> under penall,of law that thi. d.wumrnt and all auachmentc wary <br />wni inn in aa•rordancr with a %istem desi <br />d uttdrr m <br />direclitm or .u <br />ned <br />re <br />ar TELEPHONE DATE <br /> ? <br />t <br />g <br />p <br />p <br />e <br /> to ? are that gmdifitd personnel properly gather and r•uluate the information <br />`-?- -- - <br /> .ubmitted. Braced on rut inquire of the perwm or penome who manage they+tem. -r <br />-- ' <br />-1~-- <br />i or lho,e pct- n directl% rasp n%ihk for gathering the information, the informallon <br /> <br />uhn ittad i•, ro the best of m,i knowledge and helkf, Irnr, aceurats•, and ctmtpletr•. <br /> <br />I- awam chat (Acre <br />nificam <br />rtwltlrs for submittin <br />ralsr informathm <br />si <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PRINTED p <br />g <br />arc <br />g <br />. <br />including the pimibilih of fine and impriamna•ni For knowing yi.dalwn, <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />TS e FTAY LET?--t- _01T RFgV_.Ty THIS OUTFAL?_ IF NOT- <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be t:sed This is a 4-ptt filrm. PAGE OF