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PERMITTEE NAME/ADDRESS dnclude Fadhl. Name Lrxnlrun dDi to-rnr, 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 />F - FINAL ME54 <br />??HRf?i+IIC WET TESTIPJG FOR 001F; <br />f, <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 r, r. ^• -I fi x ^ r. l <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 ?crt:t, under penalty of law that this document and all attachments were TELEPHONE DATE <br /> d <br />h <br />d <br />d <br />, <br />d <br />1 <br />- prepare <br />un <br />er my <br />trn <br />oon or super tsion to accor <br />ance wit <br />a svswrn drngned <br />to assure that yuahti d personnel properiy gather and evaluate the information <br />/ 1 ^ s <br />` <br />_ submitted Based on my inquiry ol'the person or persons who manage the system. 1 <br />n L + ?? <br /> or those persons directly responsible for gathcnng the intomtation. the information V <br /> to the 1,<st of my knowledge and belief <br />accurate <br />and complete. <br />submitted is <br />true I <br /> . <br />, <br />, <br />, <br />I am aware that them arc si <br />nificant <br />fcx <br />ubmtun <br />false mfnmtattun <br />enaltie SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />g <br />, <br />s <br />s <br />p <br />violnt3trts <br />mcludm <br />the <br />ossibility of fine and imprisonment fart knowin OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> . <br />g <br />g <br />p CODE <br />COMMENTS AND EXPLANAI IUIV Ur- aNT VFULAI IUNJ Irreverence an arracnmenrs nere) <br />EDUVE RTP <br />LNG CODE "P <br />AT WHICH STATISTICALL'Y' <br />CH CHRON TOX TFST RPT TO DMR <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. - (02 1 O TtW U-% ;OfB form.