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PERMITTEE NAME/ADDRESS //nesb4f etlkryNw?(oeaee«VD(QIw«s) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM //NPOESJ <br />DISCHARGE MONITORING REPORT IDMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OM13 No 2040-Orf4 <br />NOTE: Read Inetructlone bofwo tiompllting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br /> <br />EX FREGUENCr <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 />MEMTLE PRINCIPAL EXECUTIVE OFFICER t "noy under pen' 1) 0 low that thh document and .l ell.chments were TELEPHONE DATE <br />prep¦red ruder my direction or mp-Won In .ccordar,m with • system ddgned <br />NA <br />to.swre that quaMlled personnel P*"ri7 Lather and evaluate The Infonnallon <br />. <br />wrbmltted. laved on my Inqulry o( the person or persorn who ma.&Cc the system <br />or those prnom dlrwily resperMbk for gathering the Inform.tlow, the Infnrnwtlon <br />k <br />k <br />( <br />new <br />submitted h, to the best - <br />dte and belle(, 1-. accurate, and compkle. <br />-y <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />l <br />I <br /> I am aw.n tb.t there m s <br />gniftc"t pen.Ides ror wbrertnnt W r <br />.rormatlon. AREA <br />TYPED OR PRINTED Inchedlnt the ponibMIty ofnne and imprisonment ror knowing .+ol.uorm OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lReforenc• rl// •ttachmonto hero) <br />EPA Form 3320-1 (Rev 199) Previous editions may be used This is a 4-pan form.