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PERMITTEE NAMEJADDRESS,lncludr l ucilin Nam; (noun u; it li fln.nri <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPOES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <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 /> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 crritrry tinder p•nalh or law that this document and all attachments were <br />, - diredian o <br />•n isio <br />orda <br />with <br />d und <br />i <br />ac <br />c <br />i <br />d <br />i <br />d TELEPHONE DATE <br /> es <br />prepare <br />o <br />r sup <br />n <br />n <br />c <br />n <br />r <br />a %y% <br />ent <br />gne <br /> to it ure that qualirred personnel proprtt? gather and esaluate the inrormmiorr <br /> submitted. Haled on ms inquir+of the promo or p-oi, wbo manage the yslem. <br /> or those pen.ms direclh r I on%ihk ror gathering lire inforttwtion. the infornuition ' <br /> submitted is, to the hest of trio, knowledge and belief. true. accurate. and complete. <br />I am aware that then. are signirwant pemdties for suhmilling raise inrurmalion SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED including the pnsihilin of rim and imprisrmment for knowing •iolawo- OFFICER OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />AND EXPLANAIIUN OF ANY VIULAIIUNS (Hererence all attacnmerlts here) <br />ECTE <br />EPA Form 3320-1 (Rey 3199) Previous editions may be used. This is a 4-part form.