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PERMITTEE NAME/ADDRESS llnclude Famin %...... <,irh,n it !ti!/nrnr, <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. 20400004 <br />ELTA <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY <br />OF 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 crrtiQ under IK'natt, of law that this document and alt attachments were <br />rvi <br />si <br />d <br />, di <br />li <br />r <br />u <br />io <br />i <br />cco <br />d <br />c <br />with a s <br />t <br />d <br />n <br />d <br />d TELEPHONE DATE <br /> prepare <br />er in <br />r- <br />on o <br />s <br />pe <br />s <br />n <br />n a <br />r <br />an <br />em <br />e <br />g <br />e <br />un <br />e <br />ys <br /> to amore that qualified personnel pngrerit gather and -duate the information <br /> submitted. Based on my inquiry of the person or penons who manage the system. <br /> or thme persons di"cll, m I oasihlr for guthering the Information. the information <br /> suhmitted is. In the hest of m, knowledge and better. true, aerttrate. and compirte. <br />ifi <br />i <br />f <br />h <br />i <br />i <br />f <br />i <br />f <br />m <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> -mal <br />o. <br />I am aware that there are sign <br />cant Penalt <br />or w <br />m <br />tl <br />ng <br />alse <br />n <br />es OFFICER OR AUTHORIZED AGENT A <br />REA <br />TYPED OR PRINTED including the pn.ahiht, or rme amt impriwmmrnt for knowing siolatton.. <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.