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PERMITTEE NAME, ADDRESS •P:, <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 t-!!O DAY YEAR MO DAY <br />FROM TO <br />11 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />1 QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br />:X OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS I I <br /> SAMPLE I <br /> MEASUREMENT - !I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT cc• t: i (.I..r. _ ::U i <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 />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I . cnhfc under penal" „t taw that tht, d-umcnt ,md all anachments aerc TELEPHONE DATE <br /> rp:IrcJ under my direanin „r ,upon t,w;i lu accordau,-c ?, nh a ,y stem dc,tgned <br /> . <>un• 111,11 yuali6ed Im-nnel property rather and eeahhatc the mtinnwln,n <br />- - ,,nmt_d Based,m me In.µurv „t Ille per ,n „r per,n+ •eh,• inana ?c the system, <br /> Iha?JC pciwn, dlrwl resp,whle tor S,IIherlrl L• the ml- m anon, th1 infimnatnitl <br />- - Ir. I,• then .1 I my knt-Icdgc.:nd b.71c( true. accurate, mid cumpiet` <br />hen ar <br />sn <br />it <br />t <br />ln <br />. f, <br />, <br />b <br />u <br />f <br />? <br />tb <br />n SIGNATURE OF PRINCIPAL EXECUTIVE I f > <br /> <br />TYPED OR PRINTED c <br />n <br />pcna <br />r <br />u <br />nu <br />can <br />e <br />mg <br />, <br />c m <br />mn <br />an' <br />:.,ih,hty of fine and lmpn.nnment fu konsrrne vlilannn` OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />C <br />YEAR <br />MO <br />DAY <br /> ODE <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. . This is a 4-part form.