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PERMITTEE NAME/ADDRESS, Include l acdai \ameib-f rn if fnf( -rnu <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />I I <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />oMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT l <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER 1 certify under Pemdy of law that thi%d,K'umrnl and all attachments wrrr TELEPHONE DATE <br /> prepared under nn direction or iuPerositat in accordanee with a svstem designed <br /> to ? urr that qualified perwnnel pngrrly gather and esaluate the informmlion <br /> suhmitted. Rased on mi inquire of the Pe-n ur Persores who manage the system. <br /> or those pr-oarts directh responsible for gathering the information. the informalion <br /> uhmitt d is, to the I-I of - knowledge and helief, true, accuran•, and complrtr_ SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are signir"m penalties for submitting fulw information, <br />RIZ <br />ENT <br />FI <br />R <br />T <br />D A AREA <br />TYPED OR PRINTED including the pw.ibility of fine and imprisonment for knowing sitduliom. OF <br />CE <br />OR AU <br />HO <br />E <br />G D NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous eddions may be used. Phis is a 4-part form.