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PERMITTEE NAMEiADDRESS rhi.;.,b: i ,, ur: '..,....., a •: :!;-ar,.,ra:r <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX <br />NALYSIS TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> F? F _ <br /> PERMIT <br /> REQUIREMENT i ! . <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- REQUIREMENT U' ` <br /> SAMPLE <br /> MEASUREMENT <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 /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />E PRINCIPAL EXECUTIVE OFFICER <br />NAME(TITL I comfy under penalty of law that mts document and all attachments uuc TELEPHONE DATE <br />. direction or svpenvtsion m accordance with a system destgn_d <br />ed <br />rader m <br />- - <br />" prepar <br />t <br />y <br />to assurs• that qualified personnel properly gather and evaluate the info muttion - --- <br />'- <br />c submitted. Baud on my inquiry of the person or persons who manage the system. <br />the mformauon <br />the mtbrmation <br />ible for <br />therin <br />s dir <br />ctl <br />r <br />s <br />on <br />h y <br />' "• <br />_ - g <br />, <br />e <br />y <br />e <br />p <br />s <br />ga <br />or t <br />ou person <br />submitted is, to the best of my knowledge and belief. true, accurate. and complete SIGNATURE OF PRINCIPAL EXECUTIVE ' . S <br /> I am swore that there are <jgniticant pcmdties for submitting fake inti,rrnation. <br />CER OR AUTHORIZED AGENT <br />AREA <br /> <br />k <br />i <br />i <br />l <br />u <br />f OFFI NUMBER <br />CODE YEAR MO DAY <br />TYPED OR -PRINTED p <br />ng c <br />a <br />or <br />nou <br />o <br />uns- <br />mauling the possibility of line and im risonment <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may Ue used. <br />PAGE - OF <br />-