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PERMITTEE NAME/ADDRESS (Include Faeili(s Nome/1-atu n tf Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />f. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 I ce'r) under pc•nah) flan that Ihi, ch"ment and all attachments were <br />direction or w <br />rrsision in aceordanee with a system dasignrd <br />re <br />ared under m <br />TELEPHONE <br />DATE <br /> ) <br />p <br />p <br />p <br /> to assurr that yualirwd pet onnrl properh gather and es aluule the information <br /> submitted. Bawd on m1' inyuin of thr person of per,ons who manage the syslrm, <br /> or thine prntms directly responsible for gathering the information. the information <br />- wbmiued k, to the best of ms kmsslydgr and Iw•lirf, true, accurate. and complete. <br />lti <br />for submittin <br />lse inform <br />tion <br />w <br />t th <br />a <br />d <br />ific <br />m <br />en <br />f <br />I <br />[h SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />TYPED OR PRINTED are <br />u <br />ere <br />rc <br />n <br />p <br />a <br />es <br />g <br />a <br />a <br />. <br />am a <br />gn <br />including the ptnsihilin of fuze and imprisonment for knowing siolations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <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.