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PERMI7TEE NAMEIADDRESS flm•lade Facipgy Namell adorn 1/Dijlerrnr/ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS . <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />X <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 />j- MEASUREMENT <br /> PERMIT _ 1 + <br />F r r a - W I C. E/ [ SUAL <br />F--- Fri- <br />REQUIREMENT <br />MOM <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 />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I ce"ih under penalty of law that this document and all attachments were <br />i <br />d <br />d <br />di <br />m <br />i <br />d TELEPHONE DATE <br />?. n accor <br />prepare <br />under my <br />rection or supcntsnm <br />attcc <br />th a system des <br />gne <br /> to assurr that qualified liemmtel properly gather and evaluate the information <br /> submitted. Rased on my inquiry of the person or pcmons who manage the syttem <br /> or those persons directly r espunstble for gathering the information, the information <br /> <br />submimd is. to the best of my knowledge and behef, wc, accurate, and complete. <br />1 am aware that there are sienificant <br />enaluea for submittin <br />false information <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />? <br /> <br />-' r <br />?: _ <br /> <br />Y' <br />TYPEII-bR PRINTED g <br />. <br />p <br />ncludit<g the p •sstbility of fine and imprisonment for mowing sialaGons. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMEN75 ANU LXNL.ANAI IUN Ur ANY VIULAI IONS (Herefence au aaacnmenrs nere) <br />IR REC <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may De used. : ;;?jTjS iS a 4-pan COTITI.