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PERMITTEE NAME/ADDRESS Unclude Facdirv -Vame/Lararion if IA]Jrrrno <br />NAME <br />ADDRESS <br />-? C <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-ODG4 <br />JC <br />iNAl_ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX NALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS A <br /> SAMPLE 114 J s1 <br />C <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - ; <br /> PERMIT _ <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penaitr l' las that this document and all auachments sere <br />prepared under my direction or superruion in accordance. itha ssetem designed 1 > TELEPHONE DATE <br /> to assure that gtmlined pertionnel proWd,, gather and evuluaw the inrormation _ - - -- <br />1/' <br />- <br />- <br />' submitted. Rased on my inquiry or the person or persons uho manage the cysrem. <br />-isle ror gathrring the information. the information <br />oe <br />rsons directs rm <br />r th _ <br />/ <br /> l <br />o <br />r <br />pe U I t t / 3 <br />?."-. uhmitltd is, to the lest or my knosledge and belief. tne. accurate. and complete- SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />r I am aware that there an-.ignincant penaltie,, for submitting false information. <br />R AUTHORIZED AGENT <br />FI <br />AREA <br />MBER <br />YEAR <br /> <br />TYPED OR PRINTED including the posibilil% of rive and im ri%onment for kmtwin i Iatiun. <br />g p g' "' OF <br />CER O NU <br />D MO DAY <br />COMMtN 15 ANU rAl-LA411 t Ivry ur rtv r vtvt_r+t rvtw rncrcrcns c on w.a .......... . .... r <br />PAGE OF <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used "Tllisis a =t-Dart form