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Form Approved. <br />PERMITTEE NAMEIADDRESS !include Facility Nameil"arion if bifferenti NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No- 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY TO YEAR MO DAY <br />ARR E'--, FROM NOTE: Read Instructions before completing 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 i r <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif% under penally of law that this document and all attachments were <br />a <br />d u <br />d <br />y di <br />tio <br />i <br />i <br />i <br />d <br />i <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> prep <br />re <br />n <br />er m <br />rec <br />n or wp- <br />on <br />a y.tem <br />s <br />n accor <br />ance w <br />t <br />es <br />gne <br /> to assurr that qualified perrvmnel properf% gather and evaluate the information <br /> submitted. Based on mN inquire of the pe-n or persons who manage the system. <br />or those pemins di-tis nrponsihk for gathering the information, the informatio •. / <br />n i <br /> submitted is. to the best of m? knowledge and helier, true. accurate, and complete. <br />I am aware that there are significant penaltir% for submitting false information <br />SIGNA RE OF PRINCIPAL EXECUTIVE I I -- <br />TYPED OR PRINTED . <br />including the Iw syibiliq of fine and imprisonment for knowing yitdatinns OF CER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />1r1 C1 CI C/If.G QII tlll tll:l ll IICIIIJ IIC/Cl <br />4 A REASONABLE <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. <br />G ! This is a 4-part fonn.