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PERMITTEE NAMEIADDRESS include Facility AamelLocation if lhJJufatl 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 C 0 Fj I F. FROM YEAR MO T YEAR MO DAY <br />O <br />t~f 1_A MAT 10:4 MANAGE= <br />Form Approved. <br />OMB No. 2040-0004 <br />it F. <br />ROU <br />NOTE: Read Instructions before ?ompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO- FREQUENCY SAMPLE <br /> <br />EX OF <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 r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMErfITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />direction or supenisian in accordance with a system designed <br />re <br />ared under m ?. <br />\ TELEPHONE DATE <br />p <br />p <br />y <br />to assure that qualified personnel properly gather and esaluate the inrormation <br />submitted. Rased on m% inquln of the person or persons who manage the system- _? . <br />or those persona dlrecth responsible for gathering the information. the information <br />submitted is. to the tn•a of my knowledge and hers!, true, accurate. false and complete. <br />I an, xwnrr ih:N ihrrc jr,- signifi. <br />am prnultiea for submitting alse information SIGNAT RE OF PRINCIPAL EXECUTIVE <br />. <br />TYPED OR PRINTED mcludtne the p :.tbiho d finr and imprisonment for kni-my, siuL tiom. <br />I OFFICER OR AUTHORIZED AGENT AREA DE NUMBER <br />CO YEAR MO DAY <br />COMMENTS AND EXPL.ANA I IUN Ur AN T VIUL.A I wrvs (hfererence an arracnmenrs nere) <br />-n r grfyt I?-r T t, ,F:?cr?,.tAljf..F anTF'R1TTAi. ANANI-Y"' q 9r <br />EPA Form 3320.1 (Rev. 3199) Previous edtttons may be used. This is a 4-part form. PAGE OF