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PERMITTEE NAME/ADDRESS (include Facilin "tarot,/ -alion if DiJ/rrenn 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 />TING FO,' <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 1 <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 I artifs under penalty of law thus this d-ument and all attarhments were <br />prepared under ms direction or u <br />ers6ion in accordance with a system de <br />si <br />ned TELEPHONE DATE <br /> p <br />- <br />g <br /> Ito assure that qualified la•rsmumet properli gather and esuluatr the inrnrmutiott <br /> submitted. Hased un m? inquiry of the prnon or perwms who manage the s?strm, , <br /> ur those wets dimtl's resp4msih1e fur gathering the infornwtion, the infnrmaNom ' <br /> submitted i> b, the best of m.t Isrs-ledgr and helirf. true, accurate. and complete. <br />I am aware that there are si <br />nific <br />s fo <br />matim <br />t <br />lti <br />b <br />itti <br />f <br />k <br />i <br />to SIGNATURE OF PRINCIPAL EXECUTIVE <br /> . <br />g <br />an <br />pena <br />e <br />r su <br />m <br />ng <br />a <br />e <br />n <br />r <br />OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the to-sibility of fine and imprisonment for knowing siulwinns. DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-part form.