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PERMITTEE NAME/ADDRESS tlnctude FarUuy NamdLocation if lh%ferentr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ. FREOUENCY SAMPLE <br /> <br />EX OF <br />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 />NAMElnTLE PRINCIPAL EXECUTIVE OFFICER I certifi wider penall or law that this dtKUmrnt and At attachments were <br />r <br />r <br />ti <br />d <br />d <br />di <br />i <br />i <br />i <br />d <br />h TELEPHONE DATE <br /> p <br />rpa <br />un <br />er mi <br />rec <br />on or supen <br />ance wit <br />r <br />s <br />on <br />n accor <br />a %%stem designed <br /> to assure that qualified Personnel property gather and ""Ionic the information <br /> submitted. Based on my inquin of the Perim or perwms who manage the system, <br /> -or thow penuns directly responsible for gathering the information. the infnrnution <br /> submitted I,. to the bet of my knowirdgr and belief. true, -curate. and completes <br /> <br />I am aware [hat there are +igttiftcani pennitiv, for suhmilting falw information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />iminding the passibility rdfine and imprisonment for knowing siolaNaa <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MO <br />DAY <br /> CODE <br />COMMEN I S AND EXPLANA I IUN OF ANY <br />(Reference all attachments here) <br />EPA Form 3320.1 (Rev 3199) Previous editions may be used. This is a 4-part form.