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PERMITTEE NAME/ADDRESS (include Facility %ane+`Lo(alion f/ Mflerento NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DAR) <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 />1`11 114t <br />(Sul <br />$ - <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />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 /> <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ` <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penaltl or Iuw that thi, ti-nuenl and ail attachments were <br />d <br />d TELEPHONE DATE <br /> prepared under m? direction or sup-ision in accordance with a system <br />esigne <br /> in acsurr that qualified pe"autel pngwrli gather and rsaluatr the inforuurtlnn <br /> submithrl. Naw1 on my inquiry of the IwrMm or petvrm who manage the system, <br /> or those perwns dirrclh responsible rur gathering the inrorntnium. the information <br /> suhmitkd is, to the twst of my knool dgr and belief. true, accurate. and contptrtr. <br />f <br />i <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> uu, <br />I :uu ,,are that there .- significant penalties for submitting <br />idw <br />nrormat R OR A <br />F <br />IC <br />TH <br />I <br />A <br />EN AREA <br />TYPED OR PRINTED naIu ing flit ry sfbilits of fine and Imprisonment for knowing Oulation, O <br />F <br />E <br />U <br />OR <br />ZED <br />G <br />T NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This iS a 4-Part form.