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PERMITTEE NAMEIADDRESS (Include Facilirr AumdL,cari,,n if Piflernu, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />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 /> <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I ecrtih under Penaln of lax that this document and all attachments were <br />ersisitm in wrordamr with a s <br />red under m <br />dir-lion or su <br />stem d,igm•d <br />re TELEPHONE DATE <br /> p <br />? <br />p <br />pa <br />y <br /> to assure that qualiried personnel properly gather and esaluate the inrormalNm <br /> cuhmitled. Haled on ms inquire of the person or perams who manage the s%slem. <br />' <br /> or those persons dircctl% n•-.winsiMe for gutimring the inrurnwtion, the infurtnation <br /> suhn imd n, to the I-t of m% hno%ledgr and ht-lief. Irue. accurate. and complete. <br />h <br />w <br />t Ihe <br />- si <br />if <br />t <br />e <br />ulti <br />s fo <br />s <br />tii i <br />fals <br />i <br />f <br />matio <br />I <br />• th <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />" <br />TYPED OR PRINTED nn <br />rc on <br />gn <br />ican <br />p <br />n <br />e <br />r <br />u <br />n <br />ng <br />e <br />n <br />or <br />n. <br />am a <br />a <br />including the pwsibdin orrine and imprisonment fur knowing siolati.m. OFFICER OR AUTHORIZED AGENT CREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY <br />EPA Form 3320-I (Rev. 3/99) Previous editions may be used This is a 4-Par[ form.