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PERMITTEE NAME/ADDRESS (include fe da% Aasnedmat(on y Affrrcnt, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (DIR) <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 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER l certif% under penalty or law that this document and all attachments were <br />ection o <br />enisio <br />o <br />e with <br />r <br />rrd ut <br />l <br />r <br />, di <br />v <br />i <br />c <br />dan <br />v <br />m de <br />i <br />t <br />d TELEPHONE DATE <br /> pr <br />pa <br />a <br />r <br />m <br />r <br />r <br />up <br />n <br />n a <br />c <br />r <br />c <br />s <br />gne <br />, <br />r <br />a, " <br /> to assure that qualified tests nnel properly gather and evaluate the inrormation <br /> submitted. Rased on m% inquiry of lbc• person or q•rsms who manage the system, <br /> or those penoms dimtly restaursible for gathering the information, the information <br /> submitted is, to the best of m% knowledge and ta•licf. tnte. accurate, and complete. <br />uiric"t <br />rnatti- f- sohmitfng false information <br />I am awarr that there arc si SIGNATURE OF PRINCIPAL EXECUTIVE <br /> g <br />p <br />. <br />OFFICER OR AUTHORIZED AGENT <br />A <br />REA <br />TYPED OR PRINTED including the possibility of nine and impri-nment for knowing violations. <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. , . This is a 4-part form.