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PERMITTEE NAME/ADDRESS (include Far"..\amenaraAan iJDifferenrt NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS L.• <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />1 faM 1, L i R <br />Form Applpved. 0 <br />OMB No. 2040-0004 <br />MINI <br />(8U: <br />1= <br />DIS+ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />_ SAMPLE <br />MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT J <br /> PERMIT <br /> REQUIREMENT j <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT li - <br /> <br />PERMIT <br />, 17, 17-7 <br />r t I <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ` <br /> PERMIT , <br />i <br /> REQUIREMENT <br /> SAMPLE I <br /> MEASUREMENT j <br /> PERMIT ! , <br /> REQUIREMENT <br /> SAMPLE jt <br /> MEASUREMENT ' L ( r <br /> PERMIT „ ,. ... - <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalp of low that this d-vmenl and all nllachmen(s were TELEPHONE DATE <br /> prepared under my direction or wpeni%ion in avcordance with a system designed <br /> Io assure that qualified perwrnnel proprrly gather and esalunte the information 1 <br /> submitted. aused on my Inquiry d the pcnrm or prraons who manage the system. <br /> or Ihosc penons directly re,ponsihle for gathering IM Infarmalion• the Information <br /> wbmiutd i <br />m the best of my knowledge and N•lier <br />lnte <br />accurate <br />and com <br />lete <br /> • <br />, <br />, <br />, <br />p <br />. <br />1 am aware that there ar <br />nifk <br />lti <br />s ru <br />b <br />si <br />nt <br />itti <br />f <br />lw i <br />f <br />ti SIGNATU E OF PRINCIPAL EXECUTIVE I <br /> <br />PED OR PRINTED <br />T g <br />e <br />a <br />pena <br />e <br />r su <br />m <br />ng <br />a <br />n <br />orma <br />on. <br />i <br />l <br />di <br />h <br />iNl <br />f f <br />OFFI R OR AUTHORIZED AGENT <br />ARE <br />A <br />Y nc <br />u <br />ng t <br />e poss <br />ity o <br />ine awl imprisonment for knowing violations. <br />' D <br />NUMBER <br />CO YEAR MO DAY <br />AND EXPLANATION OF ANY VIOLATIONS <br />here) <br />NA <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used.