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PERMITTEE NAMEIADDRESS (include Facility A'amel ocauon if biJJerva) <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 />Mir <br />F <br />MII <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 SAMPLE <br /> EX S <br />TYPE <br /> ANALYSI <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMErrITLE PRINCIPAL EXECUTIVE OFFICER I .ertir, under Penalty of law that this d-woment and all attachments were <br />TELEPHONE <br />DATE <br /> prepared unda•r my direction or .upeni.inn in -irdanre with a cy%tem drsigrwd <br /> In a-ure that qualified personnel prnperii gather and c.aiuatr the information <br /> submitted. Rased nn my inquire of the person or per,om who manage the %.+Irm. <br /> or three pereom directly respwn;hk for gathering the information, the information <br /> .ubmitted i+. to the test of m% knowledge and belief, true. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> I am aware that ihrre arc signirtcant Penalties for smbmilting false information. AREA <br />TYPED OR PRINTED including the pmsih0iw of fine and imprisonment for know ing.iolatinns. OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />CCIDE <br />YEAR <br />MO <br />DAY <br />COMMMrV I, AMU tAYLAPlA I iUrv Vr mrm T vtVLA t tuvia (r7C/C!Clrt'a nn auawnnmrw raw c/ <br />,MTT•.?T!!r ?^ Pr-0019rI) TO '_1?'I.IRM.T'T A REOUFST FOP. A <br />PAGE OF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-pan form.