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PERMITTEE NAME/ADDRESS (Include F'aciGf)Aam<s9s'arLnt if P>fjerenlj <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <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 />mir <br />{ Sl <br />r _ <br />Form Approved. <br />OMB No. 2040-0004 <br />V T SON R <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <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 certirl under penalt.s of lae that IN, d,wumara and all atachmettts wen <br />i <br />d <br />i <br />h <br />t <br />d <br />d <br />- TELEPHONE DATE <br /> gne <br />Prepared under m) direction or.upers <br />ision in accnn <br />ance w <br />t <br />a - <br />ent <br />es <br /> to aswre that qualified la•rsomu l properh gather ant er ahmte the informafion <br /> suhmitted. Rawd an m) inpdrs of the person or per,tm+ whu munagr• the yctcm. <br /> or Those per.ons direcfh respm.iNt, for gathering the information, the information <br /> .uhmiurd i,. t., the trest of m% kn-trdge and belief. true. accurate. and complete. <br />h <br />i <br />i <br />f <br />l <br />i <br />f <br />ti $IGNATU RE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware tb.u Iban :u -ignifieunt penaltie, for su <br />m <br />tt <br />ng <br />a <br />se <br />n <br />orma <br />on. <br />including thr 1H . thilit ! fine and imprisonment for knowing •iolutitms. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.