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PERMITTEE NAME/ADDRESS (include Facililt Samell.ocatiat if Diffrremt <br />NAME <br />ADDRESS <br />NI <br />FACILITY Idl <br />LOCATION r.fl <br />ca E <br />IF MANAGE <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY Y 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 SAMPLE <br /> <br />E OF <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - .i.;.I <br /> SAMPLE <br /> MEASUREMENT ` <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT I. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = ... , . <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT i' <br /> <br />PERMIT R* V, Ir 11 it i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT J <br /> PERMIT t :• sr r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I ,rrtir, under panda of Iuw that this document and all attachment% were <br />di <br />i <br />) <br />d <br />Ki <br />d TELEPHONE DATE <br /> prepare <br />mt or wpm <br />nn in aacor <br />un <br />er nts <br />nmt <br />ancr with a %?Mcm do itned <br /> to assure that qualified re-nnel proprrl? Rather and evaluate ttx inronnatlon _ <br />"- submitted. Hand on m% inquln of the per.wt or wi-ats who manage the sv stem. <br /> or (hose pervwt direcils responsible for gathering the infuriation, the information - <br /> submitted K, to the best of m% kn-lvdgr and helkd, true. accurate. and complete. <br />1 am aware that there are signirkynt penalUec fur wbmitting fuKe information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />inhaling the F-ibilits of Me.and impriwnment far knowing tinlat4ms. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />F1 EVEl' <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. - This is a 4-part form.