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PERMITTEE NAME/ADDRESS ilnclude Facility Name/Location if Diffirenfl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />71C A i t 1 : YEAR MO DAY YEAR MO DAY <br />LOCATION ;)EN FROM TO <br />KA n. RF.' <br />Form Approved <br />OMB r1o 23:p-0004 <br />M T fv iv ?`'. <br />(SUER • <br />F - F I' <br />DSCHG to <br />N)TE: Read Instructions before ComDIetinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> <br />E OF <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ?I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> A J ^ <br /> SUREMENT <br />ME I .,l <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i <br /> SAMPLE <br />? <br /> MEASUREMENT v ? <br />1 <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I terlip under pen:dn (4 1- that this document and all attachments were <br />r <br />a <br />d und <br />r <br />dir <br />cti <br />n <br />r <br />u <br />"t <br />n i <br />c <br />ss-iih <br />l <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> p <br />rp <br />re <br />e <br />m? <br />e <br />o <br />o <br />s <br />re" <br />o <br />n a <br />cur <br />unce <br />a sy, <br />em <br />gne <br />es <br /> u. assure that qualired personnel properly gather and esaluatr the information <br /> submitted. Based on my inquiry or the person or pers.., who manage the, ystem. <br /> or thus, persons directly rcrPon%a4e for gathering the information. the inrormalion <br /> whmitled is. it, the hest of my Anomledgr and belief. true. accurate, and complete. <br />1 am aware that them are significant penalties for suhmilting falx inrormation <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />including the prwsibilits or nine and impriwnmcnt fur knowing sitdation%. OFFICER OR AUTHORIZED AGENT COD NUMBER YEAR MO DAY <br />GUMMLN 15 ANU LXPLANA I JUN OF ANY VIULA I IUNb (rrererence an arracnmenrs nere) <br />OYR, 24HR PREIIP EVENT <br />a.JECT TO PROOF OF BUR <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used - • This is a 4-parl'form.