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PERMITTEE NAME/ADDRESS llncludr Facility Namdl oculion if Di/Jerrnfl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />R <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 />v <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br /> <br />OF <br />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 />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I certif% under plnalts of law that this document and all atachmcnls sere TELEPHONE DATE <br /> prepared under m? direction or wpcrsisiun in accordance with a s4rnt drsigned <br /> to msurr that qualified pc-onel properly gather and esnluilr the Inrormatiom - <br /> submittal. Based on n,7 inquir, of the prrwn or person, who manage the sl%tem. _ <br />• or those penons dirmth repamsiblr for mothering the infornwtion, the information -- " <br />I <br />- to the iw t of m.s knowledge and helief <br />accttrale <br />and complete- <br />submitnd is <br />true <br /> <br />" . <br />, <br />, <br />. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I um aware that there are vgnificant penalties rim submitting rape information, <br />k <br />owi <br />th <br />ihiiit <br />f fine <br />d i <br />i <br />o <br />e <br />t fu <br />ciol <br />tom <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED n <br />. <br />e poss <br />, o <br />an <br />mpr <br />s <br />nm <br />n <br />r <br />nR <br />a <br />nc <br />u <br />ng DE <br />UUMMCIq IJ ANLJ CAYLAIVA I tVry Vr AIgT VIVLA 1IV19a InC/Cr crn,c an a.10l.luRCn1J rrmc/ <br />f0YR/24HR PR <br />20. 30 DAY <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used - This, 1s 0 4-0art form.