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PERMITTEE NAMEIADDRESS !include Facility .4amdLoration if Di fermi <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 />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYP <br /> ANALYSIS E <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMErrITLE PRINCIPAL EXECUTIVE OFFICER I --il under penult% of In% that this d-ument and all attachments were <br />Prepared under to direction or suprr%Wim in a Tordance with a s <br />stem designed TELEPHONE DATE <br /> } <br />to aswre that qualirted perxmnel propert) gather and rsaluate the information <br /> submitted. Rased on - inyuin d the person or prt ms w ho manage the system. <br /> or thine per- directi- resppmsible ror gathering the inforrami,m, the Inrorn ution <br /> suhmitted Ls, to the best of m? knowledge and Ixher, true, a[curate. and compute. <br /> I am aware that there are significam <br />enalties for submittin <br />Inter rnrh-ntimwt SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED p <br />g <br />imkiding the possibdits if fine and impris content for krawing sndao ,,,. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3'99) Previous editions may be used. This is a 4-part form.