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PERMITTEE NAME/ADDRESS Ilnclude Facility N'amell"irtion if Differenfl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />(St <br />1• <br />MW <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 - <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 /> <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 cer ifs under penalo of low that ibis document and all attachments were <br />d <br />i <br />t <br />d <br />d <br />d <br />di <br />i <br />L <br />i <br />d <br />, <br />ith <br />i TELEPHONE DATE <br /> wn <br />n accor <br />am <br />r w <br />u sys <br />em <br />es <br />gne <br />prepare <br />un <br />er m) <br />met <br />on or wperv <br />s <br /> to assure that gmdiri.d persrvmncl propeNs gather and evaluate the information <br /> stthmitled. 11awd on my inquire of the prison or Persons, who manage the system, <br /> <br />or Ihone penom directO rmponsihh• for gathering the information, the inrotmwUoo _ <br /> whmiued K to The best or ms know ledge and belief. Intr. accurate, and anmpkte. <br />r <br />o SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> I am aware that there are signiricant Penalties for submitting <br />aise informat <br />o, <br />including the <br />visibility of fitx and im <br />risonment for knowin <br />stdatG ns OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED p <br />g <br />p <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. . This is a 4-par( form.