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PERMITTEE NAME/ADDRESS (Include Faei6lq NamelLocation ijl)iJerenq <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 />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />(SUBIR MH ) <br />F - FILIAL <br />II;+J TO UNNED TRIG TO HUBBARE <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 <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ._' <br /> FE QUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty orlaw that this document and all attachments were <br />a <br />ed <br />d <br />r <br />di <br />ti <br />,i4 <br />with <br />i <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> prep <br />r <br />un <br />e <br />ra% <br />rec <br />on or suprt <br />on <br />n accor <br />ance <br />a system <br />es <br />gne <br /> to assure that qualified rwm)nnd property gather and rs'aluate the information <br /> ntbmiutd. Rased an m% inquiet of the person or per ons who manage the system. <br /> or tho,e prmwrs dirrrdy reslx,nsible for gathering the Information, the information <br /> submittrd'n, to the best of my knn%ledgr and hrlirf, true, accurate. and complete. <br />- 1 um awarr that there are significant penalties for suhmitting raise information SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />TYPED OR PRINTED , <br />including the pa siblity or line and imprisonment for knowing Oolatko OFFICER OR AUTHORIZED AGENT AREA <br />CODENUMBER <br />YEAR <br />MO <br />DAY <br />GUMMLNI, ANU tA.YLANAIIUN Ur ANT VIUL.AIIVNJ (mererence all anacnmenrs nerej <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This iS a 4-part form.