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PERMITTEE NAME/ADDRESS dnclrrde Pac!!fry Numz4.ocmion ijUi//errml <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />?!,•, MEASUREMENT <br /> PERMIT - I 1 C i `: _fA? <br /> REQUIREMENT MrIN <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 cernfy under penalty of law that this document and all attachments were TELEPHONE DATE <br /> pr-Iwred under my drrecnon or supenisaon in accordance with a system designed - <br /> <br />S to assure that qualified pcr5otmcl pntpcrly gather and evaluate the information ?'. <br /> submitted. Based on my inquiry of the person or persons who manage the system, <br /> or three persons directly respoasiblc for bothering the information. the information <br />' e d as, to the best of my knowledge and belief, true, accurate, and complete <br />h <br />t th <br />lti <br />b <br />itti <br />l <br />f <br />i <br />fi <br />f <br />f <br />f <br />n SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />TYPED 09--PRINTED mu .ur..,:c t <br />or su <br />ng <br />orrna <br />on. <br />a <br />ere arc s <br />gni <br />cant pena <br />es <br />m <br />a <br />se m <br />n.:ndoi_ ihr lwsahiliry of fine and impnsonment for knowing violation`. <br />OFFICER OR AUTHORIZED AGENT <br />AREA CODE NUMBER <br />YEAR <br />MO <br />DAY <br />L:UMMENT5 ANU EXPLANAI IUN Ur ANY VIULAI IUNb (Hererence an arracnmems Rere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. r)o 1 c?Ci ; ThJ$ is :a 4-pare. fonn.