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PERMITTEE NAME)ADDRESS(7m"FarM4M.rrL«atlow(/D(66rwv) <br />NAME <br />ADDRESS <br />FACILITY 1- <br />LOCATION iE <br />G. <br />NATIONAL POLLUTANT DISCHAAGE FUMINAT1oN SY3TEM (IVPDES) <br />DISCHARGE MONITORING REPORT (D MR) <br />PERMIT NUMBER DtSCHAAGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Rssd k»tructlons before completktp this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />F SAMPLE <br /> EX O TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE l <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 E L <br />NAME/TTTLE PRINCIPAL EXECUTNE OFFICER 1 Bert iy u prna y o le. that thte do n%rnt end all altnchments .ere <br />TELEPHONE <br />DATE <br />PITMrs'd under my dlrerilon or wprrefslon In ascordaeece .Ilh ¦ s]stem ddgned <br />to aaure that quallnrd personnel Property (alter and eeelusle the Informellon <br />- submltled. Bead on my Inatulry of the Person or persoru ho mane=, the system. <br />or Ihosr perms directly respotdbk for rltlherlng the Irtformallnn, the Informalhm <br />submllted N. to the best of my kno.kdge and beMef. Irve• ti-srfle, at.d compkle. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am e.ere that there are drntncant penalises for submitting rater Information. A A <br />TYPED OR PRINTED InNuding the possibility of floe ¦nd Imp, w. meet for Itno.ing ,lchtk s. OFFICER OR AUTHORIZED AGENT NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION Of ANY VIOLATIONS (Reforsnce sat strechmentt hers) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This i5 8 4-pan form.