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PERMITTEE NAME/ADDRESS (Include Farilin ,Nam(1-atitat Y 16ff, roll <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />I--- PRE <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 />Form Approved. <br />OMB No. 2040-0004 <br />t5 <br />F• <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rerttf under penalq of law that lhl. document and ail attachment were <br />prrpand under m, dire 'limn or wtper%Nunn in accordance with u -stem drreigned <br /> <br />TELEPHONE DATE <br /> tm <br />that yualiried perstrnnel properle (rather and ecaloate the inrormuti+m <br /> .uhmitled. Ra+ed on m7 inquire of the per.on or p-me who manage The sy>tem. <br /> or Ihm.r lwnom directi, rreptmsildr for gathering the information, tiw• information <br /> whmilled ie• to the beet wf my knowledge and belief. true, accurate, and cotnplrlr. <br />I am aware that there arc eivnirw'am Penalties rur submittin <br />rule mrormatioa <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br /> <br />TYPED OR PRINTED g <br />. <br />fnrbdin The t rdrilit td (ae and im rn <br />nmrnt for knowing notations. <br />K r'n P " <br />OFFICER OR AUTHORIZED AGENT <br />AREA CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF AN <br />(Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.