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PERMITTEE NAMEIADDRESS (include Facility rr'amdl o ation if Dif irent) <br />NAME <br />ADDRESS I" <br />UiJX .?x:ti= <br />FACILITY OR I Z <br />LOCATION <br />IiNCF- <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 />V t FROM TO <br />WE-R <br />Form Approved. <br />OMB No. 2040-0004 <br />? 1 <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 /> <br />REQUIREMENT i MIA X 1ry <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 77 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />- <br />7 <br />- <br /> PERMIT 7 T7 <br />-7 <br />77 a <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F ., <br /> REQUIREMENT r;: i9: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' r. <br /> REQUIREMENT - <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under la•nally of law that thi. docmnrnt and all attachments were <br />ctio <br />emsin <br />ac <br />with <br />s%zt <br />e <br />d und <br />r <br />dir <br />o <br />s <br />i <br />ord <br />n <br />t d <br />si <br />ed TELEPHONE DATE <br /> pr <br />pare <br />e <br />nn <br />e <br />n <br />r <br />up <br />n <br />n <br />c <br />a <br />ce <br />a <br />eu <br />e <br />gn <br /> to o» ire that qualirwd Wminnel prof rd*i gather and eyaluair the information - --- - <br />- - -- -- -- .uhmitted. Based on m) inquire or the per>,m or person. who manage thr system, <br /> or thou persom directly responsible for gathering the information. the information <br /> <br />-- submitted b, to the 1-1 of mf knosdedge and belier, true, accurate. and compieta <br />lti <br />bmitti <br />false i <br />I <br />m <br />w <br />th <br />t th <br />r <br />ni <br />iric <br />t <br />n <br />s fo <br />for <br />tion SIGNATURE OF PRINCIPAL EXECUTIVE " <br /> <br />TYPED OR PRINTED . <br />a <br />a <br />are <br />a <br />e <br />e are <br />gn <br />an <br />pe <br />a <br />e <br />r w <br />ng <br />n <br />ma <br />imiuding the p„ssibili" of fine and impri.onment for knowing violation.. <br />OFFICER OR AUTHORIZED AGENT AREA <br />COD NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Forth 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-piirt fornl.