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PERMITTEE NAME/ADDRESS (include Facid'ty h'amell ocarion if l)i ferenr <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 <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 /> <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 /> REOUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under Ieoauy or law that this document and all attachments were <br />d <br />d <br />l <br />h <br />d <br />i <br />c TELEPHONE DATE <br /> prepare <br />under my <br />ire <br />tion or superytsion in uceun <br />anco wit <br />a system <br />es <br />gntd <br /> Io assure that qualified personnel properly gather and evaluate the information <br /> submitted. Rased on me inquiry of the person or persons who manage the system. <br /> or those Imrsuns directly respundble for galhrring the information, the information <br /> <br />submitted is, to the best of my knowledge and belief, Ina•, accurate, and complete. <br />fur <br />I <br />w <br />re that ther <br />• <br />• <br />nifi <br />nt <br />naltie <br />ub <br />ittin <br />fal <br />e i <br />f <br />atio <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PRINTED am a <br />a <br />e <br />ar <br />g <br />ca <br />pe <br />s <br />s <br />m <br />g <br />s <br />n <br />orm <br />n. <br />s <br />intluding the im-ibility of fine and imprisonmem for knowing sirdatiom. <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. This i5 a 4-Part form.