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PERMITTEE NAMEIADDRESS rlneludeFacllrn :\'rmr.? xaNnnr/1)yjrmnq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <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 />L'i_F?N <br />NOTE: Read Instructions before comDletinq this form. <br />PARAMETER QUANTITY OR LOADING QUAUTY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />tl. MEASUREMENT <br /> PERMIT a <br /> REQUIREMENT D <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT : a a t <br />( REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT Fsa?t t ^i I ?'rf J <br /> REQUIREMENT r; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t !-r t 4 Et'1JRT 1 r:. 1rY1?11 <br /> REQUIREMENT P TR. A',; <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 -na, under penalty of la% that this document and all attachmem? were TELEPHONE DATE <br />_u prepared under nn direction or supervision in accordance with a system designed <br /> <br />r ?? / .. r f to assure that qualified personnel propcrh eathcr and evaluate the information <br />submitt <br />B <br />sed on m <br />in <br />of the <br />erson or <br />ersons who marw <br />e the system <br />d <br />uir - <br />-- -"= ?_ <br /> . <br />p <br />g <br />. <br />e <br />a <br />q <br />y <br />p <br />y <br />or those persons direct(} responsible far gathenng the information- the inhmn.tm:n <br /> f <br /> submitted is. to the best of m% knLmIcdgc and {che <br />, true, accurate, and eoinpl.•t` <br />l <br />fi <br />b <br />fal <br />h <br />i <br />f <br />itt <br />f <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br /> orm.wc:n' <br />at t <br />ere are s <br />gn <br />cam pena <br />ties <br />-r su <br />m <br />ing <br />se m <br />7 ware t <br />: <br />3 OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED udmg fltc psstbrlil} u(tine and impnu:mnem for knotting cinlanc'n' <br />. <br />, CODE <br />GUMMtN IS AN L) t:AIILANAI IUN Ur ANT vIULAI IVNJ (rrelereriGe an atldGnme1195 nerd <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. Z 5 C This is a 4-part lonn.