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PERMITTEE NAME/ADDRESS ilncludr Facilur Aamr/Illfntion if Uifferrno NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMA) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />_ . , FROM TO <br />v imin. FtF%1 a7!°t,t1'f ? iNJ MANIAOF, <br />Form Approved. <br />OMB No 2040-0004 <br />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 { i <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <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 /> M <br />R <br />M <br />N <br /> EASU <br />E <br />T <br />E -- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />t. <br /> MEASUREMENT - C. <br /> PERMIT <br />1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMErnTLE PRINCIPAL EXECUTIVE OFFICER I errtif,i under penults orbtw that this d-inerit and all .1l.ehments were <br />ectio <br />or w <br />ensio <br />orda <br />e with a ssstem desi <br />n <br />r <br />u <br />d unde <br />di <br />i <br />d TELEPHONE DATE <br /> p <br />rp <br />rr <br />r m% <br />r <br />n <br />p <br />n <br />n acc <br />nc <br />g <br />e <br /> to-(,r, that qualified personnd prolerly other and rsatuate the information <br /> submitted. Wesed on my inquire ,f the person nr persons who munatte the syvstem. p <br /> or three leru>ns directly responsible for gathering the inrormation. the information - ' _ r- - <br /> submitted is. to Ihr lest of m? knowledge and lehrr. trite, Accurate. and complete. <br />th <br />lti <br />itti <br />i <br />ti <br />I <br />th <br />i <br />ifi <br />t <br />f <br />b <br />f <br />l <br />f <br />SIGNAT RE OF PRINCIPAL EXECUTIVE s , <br />-? <br /> :mu .ware <br />eir are s <br />pena <br />es <br />or su <br />se <br />n <br />orma <br />on. <br />at <br />gn <br />can <br />m <br />ng <br />a OFF ER OR AUTHORIZ <br />NT <br />D A AREA <br />TYPED OR PRINTED including the j-ibility or fine and imprisonment for knowing si datlon E <br />GE NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Aeterence all attachments here) <br />c1: J47 : ". bi%=is ai 4-pah-ftimi. <br />EPA Form 332Q-1 (Rev. 3'99) Previous editions may be used.