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PERMIT-TEE NAMEIADDRESS ifnclud, Fw"-.4'amr/Lmation if lh(frrrnti <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />MIN <br />(su <br />F <br />ER <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 <br />OF SAMPLE <br /> EX 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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under pen:dh orlaw that Ihfi d-umenl and all attachmrnl. were <br />with a <br />d <br />irm d-i <br />ed <br />d <br />d <br />di <br />i <br />%Wo <br />i TELEPHONE DATE <br /> on or wper <br />n <br />n accor <br />ance <br />y <br />gn <br />prepare <br />en <br />er m.i <br />rect <br /> W w,%urr that tlualified pe-m•1 properir gather and real-le the information <br /> whmillad. Raid on m) inquiry of the pe-n or person. who manage the %i%tem, <br /> or those person%directl? respun%ihlr fur galhering thr information, the information - <br /> submitted is, to the tw t of m> knowledge and hriief. tote. accurate, and -mplele. <br />f <br />h <br />f <br />l <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED urnad <br />I am aware that there arc signifwvnt penaltin <br />or %u <br />mitting <br />a <br />y <br />n <br />on. <br />including the p-ihilih of fine and impriwnment ror knowine ?iolmion,. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />D <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />IVED BY W(llt <br />- PROOF <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-Part form.