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PERMITTEE NAMEMDDRESSp?rF?rwryNw?(or.+?onl/D?..w) <br />NAME <br />ADDRESS <br />FACILITY )mi'``ls <br />LOCATION EP <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM //NPOES/ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER ;-.GE NUMBER <br />MONITORING PERIOD <br />YEAR MO OAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: Reed M»tructlorw before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCr OF SAMPLE <br /> EX ANALYSIS TYPE <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 /> 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 />REQUIREMENT <br />I rtrtttr r er penalty offs. that <br /> <br />T <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER this dxjmtnl and DIN anarhmenls .en <br />ELEPHONE <br /> <br /> <br />ATE <br />prepared under my direction or wperrhlon in acrordanre .tlh ¦ system dedgned <br />Z i to inure that qualified Personnel P, Opt. my gather and evaluate the Information <br />subndlted. Bawd "my Inquiry of the Person or Persona who manage the syflem <br />or thew prrwm dhectly mponalb4 for gathering the tnfor.utlen, the Information '- <br />/ <br />erbmtli d h <br />to the b" t of m <br />kno.hd <br />and b <br />Ber <br />tr <br />e <br />. <br />, <br />rsf <br />nd <br />hl <br />j_ <br />, <br />y <br />V <br />. <br />t <br />v <br />. <br />e. <br />r <br />v. a <br />romp <br />e. <br />i am aware that then an si <br />nificant <br />enalties for submlltin <br />fake Inf <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />r <br />d <br />n <br /> g <br />P <br />g <br />o <br />ma <br />o <br />, ARE <br />TYPED OR PRINTED Including the possibility of fine and Imprisonment for knowing rldatlom OFFICER OR AUTHORIZED AGENT ODE NUMBER <br />C YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference eM effecnments here/ <br />EPA Form 3320-1 (Rev 3%99) Previous editions may be used This is a 4-part (Onn. PAGE OF