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PERMITTEE NAME/ADDRESS ilnclude Faci6ry,Vmne// ocafian if thfferen0 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NDISCHARGE 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 NO. FREOOUf NCY SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 C'= • N•`•' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I rerun under penalty of law that this document and all attachments were <br />prepared under m <br />direction or su <br />ters ision in accordance with a s <br />stem desi <br />md TELEPHONE DATE <br /> y <br />l <br />y <br />g <br /> to a-ure that quabrted personnel properls gather and naluale the information <br /> submitted. baud on my inquiry of the Peron or persons who manage the system. <br /> or tbose persons direeuy responsible for gathering the information. the informalion <br /> submitted F, to lit he,,t or my know ledge and M•bef. true, accurate, and complete <br />I am aware that th <br />re <br />ificant <br />lties f <br />b <br />r <br />si <br />en <br />s <br />ittin <br />falw i <br />fo <br />atmn <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED e <br />a <br />e <br />gn <br />p <br />a <br />or <br />u <br />m <br />g <br />n <br />rm <br />, <br />including the pmsibilih or rive and mrprisonment for knowing siolations. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS <br />here) <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.