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i <br />PERMITTEE NAME/ADDRESS ilncladr FmiGrr.1`amdl urarion fjDijjrnnb <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />LAIC E (WAVE 11"4E MA?•/IAGE <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 2040-0004 <br />i?yTRS <br />NOTE: Read InStriirtinnc hp.fnrw rmmrilatinn this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT j <br /> PERMIT f n . ,. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ . r :; ... R=='. F' -T st <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 />I REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtify under penalty of faa thug this d-ument and all attachmr is aere <br />d <br />d TELEPHONE DATE <br /> prepare <br />un <br />er in dirmilon or suprnision in accordanty with a system designed <br /> to [?\r/re that qualified pe-rawl prnpvrly gather and c%alunte the lnnsi- atn/n - <br /> <br />- - whinitted. Raved on my inquiry of the prram or persnm wlai maagc the vyvtem. <br />' or those persons directly rrspmibhr for gathering thr Inrormation. the information <br />C subndtted iv, I. the best of my knnsekdge and belie(, true, accurate and complete. <br />1 <br />am a%arr that thrrc• arr si <br />nifica <br />ltiev fo <br />t <br />sub <br />itti <br />f <br />l <br />i <br />f <br />ti <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />.......?..? g <br />n <br />p rna <br />r <br />m <br />ng <br />se <br />a <br />n <br />orma <br />on, <br />including the possibility of fine and impriwmment fnr Anossing riodaioa. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />D <br />YEAR <br />MO <br />DAY <br />e?/.v a_?/ rr/?.? /v/? v/ ??? / ?/v?e? / /v/??a 1- '.-c at, pll0{i/IIIICIIIJ IICr Cl <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. 00 0 . nit is a`4-parr form.