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PERMITTEE NAME/ADDRESS tinclude Foeil&y %amdLoc•arion If Diffrrenti <br />NAME <br />ADDRESS <br />316- <br />FACILITY <br />LOCATION 2 6 <br />,;LSAT 1 D1:1 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 />rlir <br />cs? <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 <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under pcnalh of lass that thls document and all attachmenh were <br />prepared under my direction or supenislnn in accordance with a system designed TELEPHONE DATE <br /> to assure that qualified penonnel properly gather and esaiuate the information <br /> submitted. Based on my inquin of the perwn or persons ssho manage the system. <br />or Iho.e prrsons directly responsible for gathering the information. the information k- _ <br />` <br /> submitted I%. to the beu of my knowledge and belief. true. accurate, and complete. <br />I am aware that there are si <br />nirkant <br />ennities for submittin <br />false information <br />SIGNATURE OF PRINCIPAL EXECUTIVE -- <br />TYPED OR PRINTED p <br />g <br />g <br />. <br />including the p-ibiliq of rim and Impriwnment for knowing siolutiom. OFFICE (t OR AUTHORIZED AGENT AROEDAE NUMBER <br />C 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. ri1, 1 This &a 4-part form.