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PERMITTFE NAME/ADDRESS(7*."Fwdi$yN..?La -tim((D(Qkru.Q <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHARGE ELIMINATION SYSTEM /INPOES/ <br />DISCHARGE MONITORING REPORT (DMR1 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 204040004 <br />NOTE: Read InBtructlotns before complet" 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 /> <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 nnny ..d,, penalty o ¦w that (bh doolment and air attachment, .en <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER <br />TELEPHONE <br />DATE <br />Prepared under my dlrrctIon or auper+fdon In aeeordartre with a splem, drained <br />to aware that qwe Med personnel property gather and evaluate IM Information <br />submliwd. Bued on my Inquiry of the person or p.n who mawage the <br />system, <br />or those pertora directly respondbk for gathering the Information, the information , <br />tubmtltled Is, to the but of my kmt,el dge and beMef, true. a rvw and compkte. <br />I am a.are that then: are aoBesnt penaltln for mbmftnn <br />rat= leformado <br />SIGNATURE OF PRINCMAL EXECUTTVE <br /> t <br />n. <br />TYPED pRINp IrrludlnS the peadblllty of Bwe and Imprisonment for knowing Idatlomi OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reforenc• o/l attachments hors( <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF