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PERMITTEE NAME, ADDRESS in<ltid, FacBin• Nome Location iJ Different) <br />NAME <br />ADDRESS <br />FACILITY l\ i i'a <br />LOCATION c u a <br />::,nuLi:t.t AttCnIT <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.OD04 <br />NOTE: Read Instructions before compleLnq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ;. -7 /. <br />( T <br /> MEASUREMENT % !' G' . ?i V U <br /> PERMIT <br />r;'•, t REQUIREMENT : i-i!_? l (11' f.. <br />!?7CI <br /> <br />SAMPLE / / j? <br />_ MEASUREMENT <br /> PERMIT _ :< i4#t# #r- #ii? r#tl ";O CE/ oALt <br /> REQUIREMENT 1r NT} i <br /> <br /> SAMPLE ^ t = :. / <br /> MEASUREMENT <br /> PERMIT 'r##irI( iEt:i,...a= I ####• r, c. !: ._.• =?A; <br /> REQUIREMENT 1'_IN'Tf <br /> SAMPLE <br /> MEASUREMENT / • l L <br /> PERMIT #I # ?i i x v? .. i? R= 0PT REPORT <br />rqr- .' <br />tFtP' <br /> REQUIREMENT a. AV= 1aF1IY I`i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT is #t -d S si r l r # u d #if >K i it : LON T T?sl iF<AP <br /> REQUIREMENT SENT <br /> SAMPLE n <br />.?- <br /> MEASUREMENT 5 <br />tJ' 0 0I0S l/ 311 ?- <br />h. , <br /> PERMIT =?IKT <br />` R_ T . ,r ##t#ir :(_11VTIf? l:[lR0( <br /> REQUIREMENT ..'•,%l: i, t', i t- " uOUS <br /> SAMPLE <br />L <br /> MEASUREMENT <br /> PERMIT w, T t ) T SI iA <br /> REQUIREMENT <br />NAME,?ITLE PRINCIPAL EXECUTIVE OFFICER I cernf\ under penalty of law- that this document and all anadnnent^ were ^ <br />' TELEPHONE DATE <br /> prepared under nn dirrcuun or .upen tstnn m accordance with a scstem designed <br />+ ?; / ! _ ,?+ as+urc that yunhried personnel prnpalN gather and ccaltuve the information <br />'Y <br />"? <br /> zthmitt-d. Based on inv mgmn of the penury or pc-sons uho manage the s% acm. ;t{yb v <br />. <br />( i ;?'(L <br />r <br />^ or th,,sc perwrns dnec-tiv responsthle for gathering the mformatton. the mformanon - <br />F and coin Icte <br />to the hest of my kno, lcd c and belief <br />trite <br />accurate <br />suhnimed ,s <br />• <br />E <br />- , <br />, <br />, <br />, <br />infortnation <br />w <br />th <br />t th <br />ant <br />lti <br />, f <br />+uhnnttm <br />t:d <br />I <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br />T . <br />am a <br />arc <br />ere arc stgtn <br />ic <br />per a <br />or <br />g <br />se <br />a <br />e <br />h <br />d i <br />f fi <br />k <br />i OFFICER OR AUTHORIZED AGENT DE NUMBER <br />C YEAR MO DAY <br />TYPED OR PRIN <br />ED mprisonment for <br />mtu,ng .tolat <br />ons. <br />including the possibi <br />try o <br />ns an O <br />COMMENTS AND EXPLANAIIUN Ur ANY VIULAI IUNb (Kererence an anacnments nere) <br />r -C IP FVF t?I' F3t)II.. ECT 10 7 .,RL-FIN OF PRnrF RECV ,PF-ME!'-IT s' <br />:. T CIN WITH1' <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used- -t4ii3e 9-part, PAGE