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PERMITTEE NAME/ADDRESS rlncludr furilat \amrr/,nuri.m ij AI!,rrnl, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <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. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 /> 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 />1 <br />F <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cartify under Penalty of law that this document and all attachment were <br />d <br />de <br />m <br />di <br />N <br />with <br />i <br />i <br />i <br />d <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> Prepare <br />un <br />r <br />\ <br />nc <br />oa or superv <br />on <br />n acrur <br />s <br />ance <br />a sys <br />em <br />es <br />gm <br /> to a..sure that qualified Personnel Properly gather and evaluate the inrormali,n <br /> suhmitted. Rased on my inquire of the Person or persons who manage the system, <br /> or those Person, directly ra twonsible for gathering the information. the information _ <br /> <br />- suhmimd k. to the hest of my knowledge and belief. true, accurate, and compile" <br />I am aware that there are si <br />nificant <br />enalties for submitti <br />f <br />k <br />info <br />tio SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />P <br />ng <br />a <br />e <br />rma <br />n. <br />including the I-ibility of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ; This i5 a 4-part fonn.