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PERMIMENAME/ADDRESS e7mc .s«?MgN??terrlo,yn?....,? <br />NAME <br />ADDRESS <br /><.E F" <br />FACILITY <br />LOCATION <br />L <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM //NPOES) <br />DISCHARGE MONITORING REPORT (OMR) <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: Reed Inetructione before completlno this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br /> <br />EX FREOUENCY <br /> <br />OF <br />SAMPLE <br /> <br />TYPE <br /> > <br />< ANALYSIS <br /> - AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />UREMENT <br />M <br />A <br /> E <br />S <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I r ? <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I to^'lr and" Pena If o law that this cl c mewl and all attachment' wen TELEPHONE DATE <br />prepared ender my dlreetlon w supervision In scrordanrr with a s)slern designed <br />to Gown that qualt ned personnel property gather and evaluate the Infornatlon <br />submilied. Based on my Inquiry of the person w persono who manage the system, <br />or thaw perwro direetly responsible fm gathering the Information, the Information <br />submltled Is, to the best or my krsawkdge and betlef. Im,. accurate. and comiekte. <br />I am awon that then on si <br />nificant <br />enalties r or submitnn <br />hl a Infnrnatl <br />ZIONATVRE OF PRINCIPAL EXECUTIVE <br /> g <br />p <br />g <br />n, <br />TYPED OR PRINTED trwiwing the possibility of fine and Imprisonment for knowing IolstJom OFFICER OR AUT14ORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference sal attachments here) <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used This IS a 4-pert form, PAGE OF