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PERMIT I LE NAME ADDRESS <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 /> <br />NOTF• Ream Inetntcfinne. hnfnrn rmmnlntino this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ; <br /> MEASUREMENT <br /> PERMIT Ib ; t- <br />= REQUIREMENT i- <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 cert,N under penalty of Ina that this dtxutnent and all attachments were TELEPHONE DATE <br />_ prepared under tiny direction or supen tsmn to accordance with a system designed <br /> to assure that qualified personnel properly gather and cyaluate the Information <br /> submitted B?cd on my inquiry of the person or per?rns who mange the %ystcm. <br /> or thou persoru mroctl7 n<p.mstble for gathering the information. the infiirmahm <br />- - uhmutccl is, to the best of my knowledge and helwt. tote. accurate. and complete. <br />I <br />r rs <br />rc th <br />t th <br />o <br />t <br />lti <br />1- <br />h <br />i <br />f <br />i <br />ti <br />f <br />l <br />f SIGNATURE OF PRINCIPAL EXECUTIVE i <br />` <br />TYPED OR PRINTED _I . <br />a <br />a <br />ere <br />re s <br />petta <br />e> <br />- <br />gni <br />ican <br />m <br />t <br />ng <br />a <br />se in <br />ormation, <br />the possibility of fine and imprivannrrn tLr knuwtnc to lutions OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR M- DAY <br /> <br />NEC IP. EVEN7 - SF <br />EPA Form 3320-1 (Rev. 3/99) Previous editiors may be used. ?1t1 1 20 This is -a 4-poit fob.