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PERMITTEE NAME/ADDRESS 1,;-:J, i'.;,i1i:• + . ?. ,r..•: 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 FREOUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . <br />EX Of <br /> <br />ANALYSIS <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />Fi 1J• <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />- MEASUREMENT <br /> t r. <br />i PERMIT R F P 0 H M <br /> REQUIREMENT ` <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> .n <br />, <br />+- n?tr <br />T - <br /> - a c <br />F <br />r ? <br />P , <br /> PERMIT <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 ,rntf% under penalty of la.. that tots document and :dl attachments wctc TELEPHONE <br />t <br />desi <br />n <br />d <br />h DATE <br />a sAs <br />g <br />e <br />cnt <br />prepared under my direction or supert tstou to accordance wit <br />as;urc that qualified personnel pmperly gather and ccaluate the infornwnou - - _y -,.-_ _ --" <br />erson or persons who manage the system. <br />of the <br />r <br />!s <br />d <br />b <br />d <br />p <br />mttc <br />on m% inqui <br />y <br />u <br />Base <br />it those persons ditecgy. responsible for gathering the miimnanon. the information <br />` <br />d+mittcd is. to the list of my krn wtcdgt and hehcf. true, accuretc, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />? ..in aware that there are significant penalties for submitting false mlormauon. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTF? •, n, {udinz the Ixiasth;hty of fine and impriwnment for knowing s iolations. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,99) Previous editions may be used. <br />PAGE OF