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PERMITTEE NAMEIADDRESS (Include FacilUy Name/Location if (Afferent, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (E)R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />SOP4 RVf <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX NALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS A <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I e'erh(y under penally odlaw Thal this don'ument and all attachmenN were TELEPHONE DATE <br /> prepared under my direction or upe"isifm in accordance with a system designed <br /> to assure that qualified pe-onel properly gather and esaluate the information <br /> submitted. Rased on my inquiry of the prrsun or pe-o% who manage the system. <br /> or three persons directly respomsiW for gathering the informution, the information _ <br /> submitted is, the hest or ms kmowledge and belief, true. accurate, and complrte' SIGNATURE OF PRINCIPAL EXECUTIVE <br />1 - I am aware that there are significant penalties for submitting raises information. AREA <br /> d i <br />risonment for knowing .iodation. <br />ibilit <br />of fi <br />e <br />l <br />di <br />h OFFICER OR AUTHORIZED AGENT E NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />ng t <br />e poss <br />y <br />n <br />an <br />mp <br />inc <br />u D <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />°IIT A REGUE37 FOr-O R <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This'IS s 4-dart f0(TTI.