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Form Approved. <br />PERMITTEE NAMElADDRESS, Include Facduy.Vamdl xcauan if fhffercull NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB NO. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />p I?iH 1 <br />ADDRESS ' <br />PERMIT NUMBER DISCHARGE NUMBER T IER 11=1 MiN <br />T (.j CALAr.I i'i DRFiW <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR O DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> <br />MEASUREMENT f . <br /> PERMIT - <br /> REQUIREMENT I•I IMU"1 <br /> SAMPLE <br /> MEASUREMENT I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE y <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT _ <br /> REQUIREMENT _. i '•, <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccrtir. under penal,., of law that this dorumem and all attachments were <br />dirm6m or w <br />ersislom in a ordance with a -lem de?si <br />re <br />ared under m <br />ned <br />- TELEPHONE DATE <br /> p <br />p <br />? <br />p <br />R - <br />- - <br /> to assure that qualified pe-nnel pnNtrrl. Rather and a-luale the information <br />- - ?` submitted. Rased on m., inquire of the W- or person, who manage the ,.stem, <br /> or those persons dimds responsible for gathering the information, the information <br />- submitted is, to 1hv 1w,1 ,4 m, knowledge and (relief, infs, accurate. and cnmprete. , > J ( <br />• - <br /> t th <br />r uh <br />I <br />aw <br />th <br />ar <br />c. <br />J <br />t <br />alties f <br />itti <br />lar <br />i <br />fo <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PRINTED am <br />are <br />a <br />ere <br />c <br />un <br />cun <br />pen <br />o <br />m <br />se <br />n <br />rma <br />on. <br />ng <br />including the bifin..f fine and imprisonment f- knowing %irtati, a%. <br />IN*?? OFFICER OR AUTHORIZED AGENT CODE AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />Previous editions ma <br />be used <br />EPA Form 3320-1 (Rev <br />3/99 This is a 4-part form. PAGE OF <br />y <br />. <br />)