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PERMITTEE NAME/ADDRESS tinrlude Pacilitr \amelLuration if Ulfferrmi <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />co S142y <br />Ar,IAGFR <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 />I.7hdIRS <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 <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 />NAMER'ITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penaltt of In. that [his doc.-I and all attachmenb acre TELEPHONE DATE <br /> prepared under ms direction or supersisiun in accordance seitir a %%%trm designed <br /> to -sure that qualified personnel properiv gather and es:duate the information <br /> submitted. Based on ma inquire or the prison or persons Mho manage the yslrm. - <br />- - or those persons directly responsible for gathering the inrorenation. the information - <br /> <br />submitted K to the hem of m <br />true <br />accurate <br />and completr. <br />knowledge and belief i <br />R <br /> . <br />? <br />, <br />, SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> I am aware that there are signincanl Penalties for suhmltting ralu information. <br />t fo <br />ki <br />viol <br />tions <br />in <br />di <br />th <br />-ihiht <br />f fin <br />a <br />d i <br />i <br />o <br />e <br />l OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTS . <br />c <br />u <br />ng <br />e I <br />q o <br />n <br />mpr <br />s <br />nm <br />n <br />r <br />ng <br />a <br />e DE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 1%) Previous editions may be used. Pfuk -is a 4-part form.