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PERMITTEE NAME/ADDRESS dndada Farilirt \umc/L+tv:inn if Differ nr 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 YEAR MO DAY YEAR MO DAY <br />FROM TO <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, <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 /> <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/T[TLE PRINCIPAL EXECUTIVE OFFICER I certir, under penalty of law that this document and all auachmenty weer <br />Prepared under m> di-tion or uper%ision in accordance with a yY <br />stem designed TELEPHONE DATE <br /> - <br />to assure that qualified personnel properir gather and evaluate the Information <br /> submitted. Rawd nn m) inquin of the Person or Persons who manage the s.stem. <br /> or those person. direeth responsible for gathering the information, the inrornmtion - <br /> submitted is, to the hest ar mi knowledge and belief. true. accurate, and complete. <br />eHner thA there are si <br />enahivs ( submitting false information <br />I am <br />nificant SIGNATURE OF PRINCIPAL EXECUTIVE <br /> . <br />g <br />p <br />. <br />OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED -Iudi.,the jo-d+hq .,(Fine and impriwnmvnt I- km wing eiolations. CODE NUMBER YEAR MO DAY <br />COMMENTS A D EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3+99) Previous eddionS may be Used. This is a 4-Part form.