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PERMITTEE NAME/ADDRESS,!,:,:r•,i: i;e _.r .. <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION Lrr.. <br />U E 164, <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />FROM YForm A <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY <br />pproved. <br />OMB No. 2040-0004 <br />NOTF Read Instntctinns before comoletlna thiS form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />' <br />' I <br />' ' <br />" <br />i MEASUREMENT <br />• <br />r <br />. <br />, <br />,?_? •,??? I ? PERMIT <br />REQUIREMENT W J <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ertif, under penall of law that this document and all attachment, were <br />r ms direction of supenuiun to accordance with a system designed <br />r <br />d und TELEPHONE DATE <br />- <br />1 r prepa <br />e <br />e <br />to asburc that qualified personnel prupe ly gather and et aluafe the information <br />submitted. Bascd on my mquiry of the Person or persons who manage the system. <br /> the information <br />the mtormation <br />nstblc for <br />atherin <br />r <br />tly r <br />s <br />th <br />d <br /> g <br />g <br />, <br />ose persons, <br />ec <br />e <br />p <br />or <br />i <br />wbmitted is, to the best of my knowledge and belief. true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ` <br /> <br />TYPED OR PRINTED I am aware that there are significant penalties for -bmnfing false information. <br />mehtdmg the possibility of fine and imprisonment fur knotting t iolations OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION Uf ANY VIULAI IUN' (He?erence an arracnmenis nerej <br />EPA Form 3320-1 (Rev. 3199) Previous edhiors may be used. <br />4HR ?REC IP. EVEN 1 - SEE I A. 1, PG. 3. FOR REOW"i't' <br />Y SAMPLING INSTr-UC 1" i ONS - I'":. 1. 7 PG. 1.4. <br />-- PACE - OF <br />Dn 1 U.?, This is a 4-part li)1 n?