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PERMITTEE NAME/ADDRESS (Include Farditp .h'ame/Incation if Uifferrntl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION 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 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 y <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 - r <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify nnder penalp of lax that thi. l-,mont and all attachrnmt -err <br />d <br />d <br />ith <br />t <br />d <br />i <br />d <br />di <br />i <br />i <br />i <br />i <br />d TELEPHONE DATE <br /> er not <br />nn or supers <br />n accor <br />ance w <br />a sys <br />em <br />prepare <br />un <br />mt <br />s <br />on <br />es <br />gne <br /> to assure that qualified prrsnnnel properh gather and ryaluale the information <br /> submitted. Based on ini inquiry of the Iunon ur persons-It,, manage the systrm, <br /> or thns,e person. direcdy re"risiblr fur gathering the information, the information <br /> stthmitted is. In the bra of m% Ion-ledge and belief. tau, acruratr, and cnmpletr. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am a-arc that then arc significant penalties for submitting false information. <br />OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the per sibilits of fine and impriammenl for krawing siolations. CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />_.,VED ,, . WQCD, <br />PR9-;- F <br />EPA Form 3320-1 (Rev. 3/39) Previous editions may be used. This is a 4-part form.