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PERMITTEE NAME/ADDRESS ilnclude Faciato'amdl Ovation if nifferent) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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. 2040.0004 <br />(buOR <br />F - f *I <br />5f4 DC C <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 <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 <ertif> under penalty of law that this doc-unwitt and all attachments were <br />prrparrd under my direction or supervision in accordance with a s'vMem designed TELEPHONE DATE <br /> to assure that qualified personnel properh gather and er aluete the information <br /> submitted. Hasid on m% inquin of the person or perVms who manage the sy Nem. <br /> or th- persons dirttcd? re,punsibk for gathering the information, the information <br /> .uhminal is, to the hest of my knowledge and belief. true, accurate, and complete. <br />I um aware that there an significant <br />enaltie, ror suhmittin <br />rake information <br />SIGNATURE OF PRINCIPAL EXECUTIVE 1 <br />- <br />- <br />TYPED OR PRINTED p <br />g <br />. <br />including the po sibilil) of nine and impri onment for knowing siolations, OFFICER OR AUTHORIZED AGENT AODA NUMBER YEAR MO DAY <br />UUMMCIY 1Z, ANU rArLANA I IUN UP AN T <br />Irieterence an artacnmenrs nerej <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part COCm.