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PERMITTEE NAME/ADDRESS 11ncLule it," ry .vame/lwttation if mfJerrnn 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 FROM YEAR MO DAY TO YEAR MO DAY <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. 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif% under penalty of law that IhH dcavmem and all attachments weer <br />d <br />d <br />di <br />i TELEPHONE DATE <br /> prepare <br />er m? <br />un <br />nrt <br />on or supervision in a(vordame with. system designed <br /> to assure that qualified personnel properly g-j1her and esaluate the information _ <br /> submitted. Based on mY inquiry or the person or persons whit mnnaer the system. <br /> ar those pe- dimk-dy responsible for gathering the information, the information <br /> subminsd is. to the hest of ms knowledge and lelirf. true, accurate, and compute. _ <br />- I ....are that there are signific,int penalties for suhmitting false information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />including the po sibihils or fine and imprisonment for knowing %iolations. OFFICER OR AUTHORIZED AGENT <br />1 AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3M) Previous editions may be used. This 1S a 4-pan form.