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PERMITTEE NAMEIADDRESS (Indmk FeciUq, Namc•Urrorien iirDij•rrrm) <br />NAME <br />ADDRESS R E}?Q M I I'VE <br />FACILITY <br />LOCATION. ? E L ' <br /> <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 />}:= 'p ; r MEASUREMENT <br /> PERMIT r - <br /> REQUIREMENT <br /> SAMPLE <br />P_ MEASUREMENT <br /> PERMIT <br />t "+ REQUIREMENT <br />( •_ SAMPLE <br /> MEASUREMENT <br /> PERMIT +• ,._ t- <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 ccrtifi under penalty of law that this document and all attachments were <br />i <br />io <br />l <br />ith <br />d <br />d <br />d <br />di <br />t <br />- <br />t <br />d <br />i TELEPHONE DATE <br /> <br /> <br />Sri <br />{ <br />? er my <br />rec <br />ion or super <br />s <br />n in aecon <br />c w <br />a sys <br />gne <br />prepare <br />un <br />am <br />em <br />es <br />to assurc that qualified personnel properly gather and evaluate the information , <br />j <br />-' <br />•, <br />-/ <br />? submutod. Based on m, enquiry of the person or persons who manage the system. - <br />Y- ` <br />-- <br /> or those persons dircoh responsible for gathering the information, the mfommtion ? <br />_ <br />,? -- <br />r-1 submitted iti to the hest of my kno•.0c4c and hchet: Ina. accurate. and complete <br />SIGNATURE OF PRINCIPAL EXECUTIVE --. <br />. - ?.- % ?7 - <br />7 I `? re that th <br />re are st <br />nifi ,I.- <br />,nt, nr t„m <br />1 <br />m <br />w • <br />TYPED Q PRINTED . <br />a <br />a <br />e <br />g <br />a <br />ibil <br />f f <br />l <br />i <br />h OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO <br /> ng t <br />e po>s <br />tty o <br />ine em <br />mc <br />ud DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. .. _ r C_ :_ ftly tS'3 3- , rt form.