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PEAmrrME NAME/ADDRESS(7,w6&Fer iyNa.WL«arow((D(06r t) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER ds2HMGExuMEER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: Read kntruc-doe befwe completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF 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 />M <br />A <br />U <br />M <br />T <br /> S <br />RE <br />EN <br />E <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <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 <br />j <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I mmty uncler Pena ty o taw that this dorvrnenl and all alfechmenu were TELEPHONE DATE <br />prepared and" my direction or mper Won In accordance with a system diedgrwd <br />to inure that quanned personnel properly gather and eealuale Ihr Infnrwlallon <br />. sob-Illed. Based on my Inquiry of the person or persons who -map the system. i ?. <br />w those persons dlrMly r F-.slbk for gathrrtl.g the Infer don, the Inrormallon <br />submllled b, to the best of my ?nawi d je and bellef. I-. tumu-Ie, and compkle. <br />- 1 am <br />Nn <br />r <br />th <br />t there <br />re <br />l <br />.t <br />en <br />lti <br />f <br />b <br />l <br />t <br />SIGNATURE OF PRINCWAL EXECUTIVE - <br />d <br />I ' <br /> <br />TYPED OR PRINTED awa <br />e <br />a <br />g <br />cas <br />p <br />a <br />es <br />or su <br />a <br />s <br />m <br />l <br />ng false <br />n <br />onation, <br />Including Ihr possibility of new and Imprisonment for knowing Wstko <br />OFFICER OR AUTHORIZED AGENT A WA <br />COOS NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference *M attachments her*) <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part form PAGE OF