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PERMITTEE NAME/ADDRESS (include Faeilily Yamerl,nurion if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />Form Approved <br />OMB No. 2040-DO04 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I -mf.s under Penaln of law that this doeutm•ni and all attachments carte TELEPHONE DATE <br /> prepared under my dirmtion or supenision in accordance with a system designed <br /> to assure that qualirid petsunnel properls gather and esahmIr the information <br /> suhmittd. Based on toy inquiry of the perwm or persons who manage the system. <br /> or those pees ms dirrrdy responsible for gatbering the inrurmution. the information <br /> submitted is, to the best of my knowledge and belief, true, u-urale. and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are signirwant penalties for submitting false information. <br />si <br />ibili <br />d i <br />i <br />t f <br />k <br />win <br />l <br />ti <br />, <br />i <br />l <br />h <br />f fi <br />OFFICER OR AUTHORIZED AGENT AREA <br /> <br />NUMBER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />TYPED OR PRINTED sonmen <br />no <br />e poss <br />mpr <br />or <br />g <br />u <br />a <br />on <br />nc <br />uding t <br />ty o <br />ne an <br />E <br />COD <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used ThTis is a 4-part form.