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PERMIT-TEE NAMEiADDRESS a,am'eFunlin'NamellAwarlonljPiffe yt) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION . <br />A?Ir•r?t`G <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 /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO FREQUENCY <br />OF <br /> <br />LYSIS SAMPLE <br /> <br />TYPE <br /> ANA <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT f,or r" _ z rya <br /> REQUIREMENT , ?. <br /> SAMPLE <br />n - • MEASUREMENT <br />i .. <br />.. <br /> <br />_ , - PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />IS...4T 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 />AME/TITLE PRINCIPAL EXECUTIVE OFFICER I cert$y under pcnaln of law that this document and all attachment. Here TELEPHONE DATE <br />N prepared under my dtrecnon or supen mon in accordance with a wstcm designed <br />- / r to assure that qualified pcrxonnel properly gather and e% aluatc the information <br />whmdted. Baud on my inquiry of the person or persons w ho manage the system. <br />the Information <br />adtcnn <br />the information <br />l <br />n <br />bl <br />for <br />h <br />di f - ->r - _ <br />_-?•? ._ ?? <br />' , <br />y respo <br />si <br />e <br />g <br />g <br />or t <br />ose person% <br />m <br />submitted is. to the best of my knowledge and belief'. true, accurate. and complete SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are stgmticant penalncs for submitting false infonnauon. OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED mclud-mv the pos>ihihty of fine and imprisonment for knowing otiolanons. CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIUNS (rtererence an aaacnmenrs nerej <br />EPA Form 3320-1 (Rev. 3199) Previous editions r,ay Le useC 1 Ills IN :I -4-part ttll'nl.