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PERMITTEE NAME/ADDRESS ,j,-:,,.: ; :rr, •rnr, <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 />RBLAN <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT Ft :> ; <br /> REQUIREMENT I <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />:.p REQUIREMENT Ir7. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r o i ; <br /> REQUIREMENT , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - . r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :? :.:} 'r x x r <br /> REQUIREMENT <br /> SAMPLE ? <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br />NAMEIITL.E PRINCIPAL EXECUTIVE OFFICER I -rtdy under penalty rd law that this dhxurnent and all attachments acre TELEPHONE DATE <br />_ prepared under my direction or .upen•rsion in accordance with a system designed <br />_ _ <br />?•y ?L , to assure that qualified personnel pmperl% gather and esalume the mGmmaunn <br />'_ <br />. suhmut ed. Based on my inquiry of the person or persons who manage the system, <br /> or th-c persons directly responsible for gathering the mti,mtauon the mfornauon <br /> k <br />l <br />d h <br />h <br />f <br />t <br />t <br />d <br />l <br />t <br />f <br />d r ^ <br /> rue. accura <br />my <br />now <br />ge an <br />e <br />e <br />, <br />e. an <br />comp <br />e <br />e <br />submitted is. to the best o <br />e SIGNATURE OF PRINCIPAL EXECUTIVE ? <br /> I am aware that there are significant penalties 6a sabmitnng false information, <br />l <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED nt <br />ons <br />including the posarhilny of tine and umpnw.nment for knnatng s,o CODE <br />COMMENTS AND EXPLANATION OF ANY <br />(Hererence an anacnments nere) <br />PAGE <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. °'? i -3c Th18 IS a 4-part fonn. OF