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PERMITTEE NAME/ADDRESS (/.dude F'orilin %'ameY1xcation if!Afferent) <br />I+ NAME <br />ADDRESS <br />FACILITY- r r?(•+? `n <br />LOCATION <br />RI f;LArii;T I ON MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />• ,w <br />rI, <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE i <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT Y <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />d <br />d <br />di <br />i <br />i <br />i <br />i <br />d <br />ith <br />d <br />i <br />d TELEPHONE DATE <br /> on <br />prepare <br />un <br />er my <br />rect <br />on or superv <br />s <br />n accor <br />ance w <br />a system <br />es <br />gne <br /> to assure that yvalified personnel properly gather and evaluate the information <br /> suhmiurd. Based on my inyuin of the persnn or persons who manage the system. <br /> or those Persons directly responsible for gathering the information. the information <br /> suhmitted is. to the best of my knowledge and brlirf, true, a urale, and cumplat, <br />l <br />i <br />f <br />• <br />it <br />ti <br />1 <br />th <br />th <br />i <br />if <br />h <br />i <br />f <br />l <br />i <br />f <br />SIGNATOE OF PRINCIPAL EXECUTIVE ti <br /> <br />TYPED OR PRINTED am aware <br />icant pena <br />or <br />ng <br />orma <br />on. <br />at <br />ere are s <br />gn <br />t <br />es <br />u <br />ro <br />t <br />a <br />? <br />n <br />rnchisling the p .: hility of fine and imPi i+ion-t I- know ing % t Iavon.. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used. Thiti is a 4-part form. PAGE OF