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PERMITTEE NAME,'ADDRESS i,:.:;,,:: i r " . „ <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />F 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 />Mir <br />JI_ <br />F- <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIS SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />- <br /> MEASUREMENT 7 7 <br />7777 7 <br /> <br />r _ PERMIT <br />REQUIREMENT r p 1? j <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I d -1"" under [knelt} of law that this dtKUmem and all attachments were <br />repared under my direction or supen,sson in accordance w ith a y stem deiigned TELEPHONE DATE <br /> p <br />to assure that yuaidied personnel properh eadter and evaluate the information <br />submitted [used on my myuin of the person or persons who manage the system. <br />th <br />formation <br />i <br />h <br />t - <br />i <br /> n <br />ormanun. <br />e in <br />e <br />or thou persons directly responsible for gathering t <br />the best of m% knowledge and bclet, true. accurate, and complete <br />h <br />d i <br />t <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE - , <br />- .- . <br /> m <br />ne <br />s. <br />o <br />- <br />I em aware that there arc significant penalties for iubmuttng false uttomtation. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />TVn?n no aGIAITGrI I •n, ludine the rtossihtlnv of fine and imprisonment for knowing si,dations. <br />COA'IMLI"TS AND EXPL,-PiAT!ON OF „ ".- .'?-ttiS iReference all attachments here) <br />Fr%EC I P. EVEN 1 - ELF I <br />Al"11'LING 1NSYRUCTIONS - <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. <br />1 i'. I. J 4-j':;!" I' !111