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PERMITTEE NAME/ADDRESS (include Facility Namdlacafion if f)i fmxtl <br />NAME :) <br />ADDRESS ILK I l-ON MINI <br />FACILITY <br />LOCATION <br />-:1 8I <br />ki-,lAGER <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- <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 /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r. n r; <br /> REQUIREMENT = - <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT _ y i`l7 <br /> SAMPLE <br /> MEASUREMENT r? <br /> PERMIT rr , r :. sr r tr sr > > r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif- under penult' of law that this document and all attachrm-n1% were <br />wi <br />t <br />d <br />d <br />d <br />i <br />ki <br />i <br />d <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> on or super% <br />a sce <br />gne <br />prepare <br />un <br />er nn <br />irect <br />on <br />n accor <br />ance <br />t <br />em <br />es <br /> to assure that qualified personnel properl% gather and esuluaty the inrormntion <br /> submitted. Nased on m> ioyuin or the person or persons who manage the s? stem. <br /> or those penons directl% resprimble ror gathering the information. the informution - - - <br />_ submitted is, to the best of m? knowledge and txlier, inrc. accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />TYPED OR PRINTED I am uware that (here are igniricant penalties for submitting fake Information. <br />including the possibilio of fine and imprisonment for knowing siolations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANAIIUN Ut- ANY VIULAIIUN5 (F!ererence an anacnmenrs nere) <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may tie used. - - - - This is a 4-part form.