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PERMITTEE NAME/ADDRESS Ifnclude Fariar.y.Vamel orati,in if mjf:renn <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 />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />( <br />F <br />ra:.t <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br />YPE <br /> EX ANALYSIS T <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 />NAME)TITLE PRINCIPAL EXECUTIVE OFFICER I crrtir, coder prnalh of law that this document and all idwhmenrs were <br />wilh a s <br />st <br />e <br />ed under mi di-e i <br />n <br />r s <br />r i <br />i <br />orda <br />d <br />I <br />i <br />d TELEPHONE DATE <br /> pr <br />par <br />o <br />o <br />upe <br />s <br />nn <br />n acc <br />nce <br />y <br />em <br />es <br />gne <br /> in assure that qualiried perwrnnel prolwrk gather and rcaluair the infurmathm <br /> suhmltted. Rasad un mr inquin or the Iwrwn or persutn who manage the yemm. <br /> or there pe-re, dire ily n tion%iblr for gathering the inrormation, the inGumatirm <br /> suh-itted'ec, to the beg of n» knowkdgc and Relief. true. accurate, and complete. <br />I am aware that there are signirwant penalties for suhmilttng fake information SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />TYPED OR PRINTED . <br />including the p-ibility ed Fine and imprrottmrnt for kni-ing siointiom. OFFICER OR AUTHORIZED AGENT CODA NUMBER YEAR MO DAY <br />AND EXYLANAIIUN OF ANY VIULAIIUN, (mererence alf affacnments nere) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-Part fornl.