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PERMITTEE NAMEIADDRESS'Inclu* FaciGlr Vameqoealion VDifferent) <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 <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, FREQUENCY <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certih under penalty of law that this document and all attachments wue TELEPHONE DATE <br /> prepared under m± dimlion or wpcnision in aecordance with a system designed <br /> In assure that qualified personnel properly gather and es aluatr the information <br /> submitted. Based on my inquin of the person or persons who manage the system. <br /> or those persons directly responsible for gathering the information, the information <br /> submitted is, to the best of my knowledge and Witt, Irw. accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there an+ignirwant penalties for whmitting false information. <br />win <br />f f <br />d i <br />t f <br />i <br />l <br />ti <br />+ <br />i <br />h <br />ibili <br />i <br />k <br />+ OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED sonmen <br />or <br />no <br />g <br />o <br />a <br />nn <br />. <br />includ <br />ng t <br />e pass <br />ty o <br />ine an <br />mpr DE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS <br />here) <br />EPA Form 3320.1 (Rev. 3M) Previous editions may be used. This is a 4-pan fonn.