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PERMITTEE NAME/ADDRESS tlnclude Facility SamrJLxation if Differnul <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION 3 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (,NPDES) <br />DISCHARGE MONITORING REPORT (DI R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />MINCII <br />Form Approved. <br />OMB No. 2040-0004 <br />MNTRS <br />P Iii TO 'LE Did <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT •} _ :; . _ . 4 <br /> REQUIREMENT M J !"I I f-ilJ:,' f. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT A <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ .. J <br /> REQUIREMENT - " I ?' `L <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t , . .. ... ., _ _ <br /> REQUIREMENT ' :. _ `• 1 ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certifi under fx udq of law that this document and all attachments were TELEPHONE DATE <br /> prepared under m? dinetirm or +uper%ision in a rurdame with a s?+Iem designed <br /> lu assure that qualified prmamel properl's galher and es abode Ile information <br /> submitted. Rased on m% inquin of the person or prnuns who manage the tfttem, <br />' " -- or [how penoas directh responsible for gathering the information. the information <br />' and com <br />lete <br />best of m <br />knuwied <br />e and belief <br />true <br />atturate <br />hmilt <br />d is <br />In th <br />1I g <br />, <br />, <br />, <br />p <br />. <br />su <br />. <br />e <br />y <br />s SIGNATURE OF PRINCIPAL EXECUTIVE - <br />/ - <br /> I am aware that there are signirkanl penalties for submitting false information. <br />wi <br />lati <br />t f <br />k <br />si <br />- <br />iMli <br />f fi <br />d i <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPED OR PRINTED m <br />ne an <br />mpr <br />sonmen <br />or <br />no <br />ng <br />o <br />including the pos+ <br />n o DE <br />COMMENTS AND EXPLANATION Ut ANY VIULAIIUNS (rrererence an arracnmenrs nere/ <br />1- 115 is a 4-pan fornl. PAGE OF <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. p