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PERMITTEE NAMEIADDRESS (include Facility.VamdLocation if Mfferentl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPOES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR <br />FROM MO DAY TO YEAR MO DAY <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 /> <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 /> 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I'erlih under penalty of Iaw that this dicumenl and all attachment, ere <br />d u <br />tiu <br />u <br />s Wi <br />-win d <br />der i <br />di <br />% <br />e <br />s i <br />-o <br />d <br />with <br />w <br />d TELEPHONE DATE <br /> prepare <br />n <br />t <br />nt <br />n <br />r <br />vp <br />r <br />n <br />n <br />r <br />unce <br />u <br />e <br />e <br /> dt assun• that quuliried personnel prowd-i gather and esaluale the information <br /> submitted. Rased on my inquiry or the person or persons who munage the system. <br /> or those persons directly responsible fur gathering ilk- information. the information <br /> suhindled is. In the trrt of m' % knawiedge and belief, true. accurate, and carriplete. <br />1 am aware that there arc signiraant penaltirs for submitting false inf a-mation SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />TYPED OR PRINTED . <br />including the possibiliq of one and impriwnnent rur knowing siulations. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />ODE <br />YEAR <br />MO <br />DAY <br />AND EXPLANA I IUN Ur ANY VIOLA I IUN, (rrererence all artacnments nere) <br /> <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. ;i?J4 ° This is a 4-part form.