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PERMITTEE NAME/ADDRESS t/nclude fariliti \anu lwnnwm of Uiffrrenti <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 NO, FREOUENCY SAMPLE <br /> OF <br />TYP <br /> EX ANALYSIS E <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c! Di' i <br /> REQUIREMENT <br />NAMErnTLE PRINCIPAL EXECUTIVE OFFICER 1 eenxk under penalty orlaw that this diavment and all attachments were TELEPHONE DATE <br /> prepui d under my dirrtion or supenision in acrnrdan with a system deaignrd <br /> to -u- that quatirled personnel properly gather and r%olewte the information <br /> submitted. Based on my inquin or the perwtm or perxms who manage the system, <br /> <br />or them penfms dimtly rt rxmsiblc• for gathering the information. the infnrmalNm _ <br /> suhmitled is, to the twat.,[ my knowledge and W- irf, true, accutnle. and complete. <br />I am aware that there are sgtnirtcani pr•naltiea rur submittin <br />ralw inrormalicm SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />, <br />including the possibility of rim attd imprisonment fur knowing siolations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />CODE <br />YEAR <br />MO <br /> <br />DAY <br />AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. - This is a 4-part forth.