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PEAWME NAME/ADDRESS pmA.&,F evMryN..?L .,i .l(Dtpl .) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHMIOE ELIMINATION SYSTEM /NPDESI <br />DISCHARGE MONITORING REPORT (DMRI <br />PERMIT NUMBER NS:C ARdfNUMS[R <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read Instructlone before completing this fwm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />Y <br /> ANALYSIS PE <br />T <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 EXECUTNE OFFlCER I tetuly tinder prna ly ° a. that this derv n m and .ii attachments .ere TELEPHONE DATE <br />prepared under my dlrxtlon or mpervllon In accordantv with • system dedgned <br />to route that qualified personnel property tolher and evaluate the Inttwmatlon <br />submtn<d. Dowd on my Inquiry of the person oe person, who manage the tyslrm, <br />or those persons directly mepon,lblt for gathering the Infonmtlo., Ike Inforr.atlon <br />- submitted b, to the best of my knowledge and belef. true, a mfe, and complete. <br />1 am ¦..- that them are sl <br />Nttcaot <br />enalties for s <br />bmltd <br />fah. Inf <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />atlo <br /> g <br />p <br />u <br />ng <br />orm <br />n. <br />TYPED OR PRINTED Including the parslbllty of fine and Imprisonment for knowing vWotlot.s OFFICER OR AUTHORIZED AGENT CODE NUMHER YEAR MO DAY <br />COMMENTS AND EXPLANATION Of ANY VIOLATIONS (Reference eN attachments herel <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used I his is a 4-Part