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PERMITTEE NAME/ADDRESS tlnclude Farilily Ndme/Locdtlon if 0ifferenti <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 F- _I <br />Form Approved. <br />OMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. OF <br /> <br />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 />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I certif> tender penah) or law Chid this Ataumrnl and all a[luchmenrs were TELEPHONE DATE <br /> P"Pamd tmdrr m. direction or super.icion in uceuniunre with a system deigned <br /> to w%surr that yunhfied per.onnel properl'i gather and e.ulu de the information <br /> submitted. Based an my Inyuir5 of the person or Person who manage the .y,trm, <br /> or thaw Persons dir vdy responsible for gathering thr infornwtion. the inrormation <br /> submitted is, to the best o( m% knuwlydge and belief, true, ucrurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are signif cant penalties for submitting false information, RI <br />FF <br />CER <br />AUTH <br />E <br />AGENT AREA <br />TYPED OR PRINTED to iuding thr ixnsibilin d fine and impristmmrm fur knowing siedation? O <br />I <br />OR <br />O <br />Z <br />D DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Fan 3320-1 (Rev 3/99) Previous editions may be used. This is a 4-part form. PAGE