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PERMITTEE NAME,ADDRESS ,h, ...... <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 />RB: <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX I TYPE <br /> S <br />ANALYS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> s w ,- <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <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 EXECUTIVE OFFICER I entry under Iwnalty ,d Iaw drat this document and all auachmem,% were TELEPHONE DATE <br />_ prepated under m? direction or supcn isiun to accordance with it s% stem designed <br /> :• a. sure that qualified personnel propetiy gather and es aluate the information - - <br /> :ubmined Based on my inquir-Y of the person or persons who manage the spsum. 1- -_ _ _ ??-- - - <br />- <br /> or Chow persons directly rcsponcible for gathering the information. the information - <br />J submitted s, to the hest of my knowledge and bchcL tmc, accumm, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - - <br /> 13m aware that there are significant penalnr. for suhmtnme false mtormanon, <br />OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />COD <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED mclwhrc the po-bdun of fine and tmpnsonment fur knowing violations. E <br />GVMMtIVIJ HfVU rnrt.HrvNttvf? yr Mir vw?s, <br />7R : 0 R, 24HR °REC iP EVFN1 - SEE <br />GRTRI_Y 54MI'L.ING 1NSTRIJCTIONS <br />7R RE <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. <br />PAGE OF <br />This is a 4-part form.