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PERMITTEE NAME/ADDRESS (include Faciffi Namell ocation if DiQerenti NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />, '«tl cal:-.. - :lf•. <br />Form Approved- <br />OMB No. 2040.0004 <br />a <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 T r <br /> MEASUREMENT -- ( v <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />I <br /> MEASUREMENT - I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ I <br />1 <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT -- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE 7 <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalt% of lass that this document and all attachments were <br />TELEPHONE <br />DATE <br /> prepared under my direction or super,Won in accordance with a system designed <br /> to -ure that qualified personnel properly gather and esaluate the information I S <br /> suhmitted. Based on ms inquiry of the person or persons who manage the system. i <br /> or thone pemons directlf responsgblr for gathering; the information. the information <br /> <br />submitt d is <br />to the hrrt of m <br />know l dge and belief <br />true <br />accurate <br />and complete L <br /> , <br />. <br />, <br />y <br />, <br />. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am awarr that there are signifkvnt pemd in for submitting fade information, <br />t fo <br />owi <br />tlmvt <br />in <br />bodin <br />th <br />m <br />ibilB <br />or fi <br />e <br />d i <br />iu <br />k <br />siol <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED s <br />e i <br />- <br />y <br />n <br />an <br />mpr <br />nmen <br />r <br />n <br />ng <br />a <br />c <br />CQMMENt5 AND tAYLANAIIUN Ul- ANY VIULAIIUNb trrererence au arracnmenrs nere) Tr! RF0QFaT F- R£ASONABLF Plf3? FI TIAL A N 00, I LYPTS 13F <br />TTS <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. IS 15 8-PdC[ form. PAGE OF