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PERMITTEE NAMEIADDRESS flnclude Facilih \arnr7nnui,m if Mffrrew, <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 /> <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 <br />OF SAMPLE <br /> EX 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 />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I cenif> under penaly of law that this document and all attachment% were <br />t <br />d <br />d <br />i <br />d <br />i <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> irection or uprrsivon <br />ance w <br />em <br />prrpared un <br />er nq <br />n accor <br />t <br />a s7s <br />ec <br />gue <br /> In assure that quAirtrd personnel properly gather and rsaltralr the information <br /> suhmalyd. Rawd on m% inquin (4 the person or pcrwms who rnanage• the svstcm, , <br /> or th- pe-n% directl's resp n%ible for gathering the information, the information - <br /> submitted is. I., the last of ms knuwiedge and Wier. ttvr, accuria, and complrlr. <br />b <br />l <br />i <br />f <br />tl <br />1 <br />h <br />f <br />i <br />f <br />i <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED .c <br />on. <br />am aware t <br />at there are signi <br />icant Penalt <br />es <br />or su <br />m <br />tt <br />ng <br />a <br />n <br />-mu <br />including the pnsibilits of fine and imprisonment for knowing sinloti„ns. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EMIT A Ri:QUESI <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.