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PERMITTEE NAME/ADDRESS ifncludr Facility Aame/Locarion if lrlffrren0 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION O F; <br />hiCfulta:'FF4 <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY <br />OF SAMPLE <br /> EX YSIS TYPE <br /> ANAL <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT = 1 <br /> PERMIT FPOr?T <br />' <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> <br />PERMIT <br />I c .. ,- W 3F- <br />a a . <br />: 'REQUIREMENT i s •i ; i x <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I e riifi noder penalo of taw that IhN document and all attachments were TELEPHONE DATE <br /> prepared under m) direction or.upr1icion in accordance with a system designed <br /> to w%sure 11121 yualifled pcrsonnd prupert) gather and esaluale the inrormation <br /> submitted. Rased on m% impin of the person or persons who manage the scslem. .. <br /> ersons directi? respuvahle for gathering the information. the information <br />or lhow - <br /> p <br />l <br />t <br /> e <br />e. <br />submitted iv, to the bestof my knowledgr and belief, true, -urute. and comp SIGNATURE OF PRINCIPAL EXECUTIVE <br />f - 1 am aware that there urc signirkunt penalties for submitting false infurrnation. AREA <br /> re nment for knowing violation <br />d im <br />di <br />th <br />ih16/v of f <br />a <br />i <br />l OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />TYPED OR PRINTS . <br />e I- <br />ine <br />n <br />p <br />nc <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IUN, (mererence an arracnmenrs nere) <br />E <br />R 10YR. 24HR PRECIP EVENT - I.A.21 <br />?O 30 DAY laUG ; S HIGHEST f-0- d i NI_.Y <br />I hI <br />EPA Form 3320-1 (Rev 3/99) Previous edaiorts may be used. I `t I, r f t [ "'