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PERMITTEE NAMEJADDRESS (Y.A k F w*ty N..WL-.teow ((DW wt) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OMCNAROE ELIMINATION SYSTEM NPOESJ <br />DISCHARGE MONITORING REPORT (D RI <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: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. <br /> <br />EX FREQUENCY <br /> <br />OF <br />SAMPLE <br /> <br />TYPE <br /> ANALYSIS <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eemly and" penalty ° Ia. that this do,,ment and DIN attachments were TELEPHONE DATE <br />prepared ender my dlrtctlon or wper.elon In accordann with • system designed <br />to more that goaHned personnel property tether and er ah,a le the Information <br />submitted. Based on my Inquiry (the Person or persons who manage the system. <br />th <br />di <br />tl <br />res <br />or <br />ibk f <br />th <br />in <br />th <br />t <br />tl <br />th <br />I <br />f <br />ti <br />t <br />or <br />y <br />p <br />or ga <br />er <br />g <br />e <br />a <br />orma <br />oa. <br />on <br />ose persorst <br />rec <br />g <br />e <br />n <br />orma <br />submitted Is. to the bet o! my kno.kdge and betlef. true, aa•urate. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I ¦m stam that (here are dgNfksM penanks for wrbmliting rates information. <br />TYPE PRINTED Inclodint the possibility of Hne and imprisonment for knowing rleistion& OFFICER OR AUTHORIZED AGENT CODE NUMEIER YEAR !LAO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference d/ attachments hot*) <br />EPA Form 3320-1 (Rev 3149) Previous editions may be used This is a 4-pan form. PAGE OF