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PERMITTEE NAME/ADDRESS dnelade FaeiUrr A'antell"adon if Mfferrn7, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />OMB No. 2040-OOD4 <br />( 5V1 <br />F •- <br />Pi Z NE <br />NOTE: Read Instructions before completinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <br />EX OF <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 /> <br /> PERMIT s <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT P1`1:11C <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certiry under penall-f law that Chi%document and all attachmenla were <br />di <br />ti <br />d <br />d <br />i <br />i <br />d <br />ith <br />d <br />i <br />d TELEPHONE DATE <br /> prepare <br />un <br />er my <br />on or wperss <br />n aecor <br />anee w <br />rec <br />on <br />a system <br />m <br />gae <br /> Co aware that qualified per,nnnel properl% gather and esaiuate the information <br /> whmitted. Rased on my inquin it( the penon or Persons who manage the system. , <br /> or those prmjns directly rt pnnsible for gathering the information, the information <br /> submitted k. to the best or my Amowledge and belief, true, accurate, and complete. <br />- - I am aware that there an si <br />nificant <br />enalties for submittin <br />fWw information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED g <br />p <br />g <br />, <br />including the jx Sihility of rine and imprisonment for knowing siolalionu OFFICER OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />l woooolr- Menu C^Vv lvmr.- yr llrer ..W rJW,Va Inerarantes all arlaRHrlrCrrta frcrn/ <br />Ft T T - <br />rt. r ,. r Q 7" ^,, e 1=1, Tt3 91JB M T T A. Rf-tll_tr7 Fns <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This-is a 4-part form. PAGE OF