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PERMITTEE NAME/ADDRESS (include £ocifirt AunerIl-toion if Uiffereni, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />5H ENGINT.' <br />Form Approved. <br />OMB No 2040-0004 <br />F?UUTT <br />NOTF• Raarf Inctntrtinnc hafnra rmmi-Ilatinn this fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <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 certify under pcn:dte of law mat this doci ment and all attachments were TELEPHONE DATE <br /> <br />` prepared u?rr m', direction or supersisi,m in accordance with a "Term desigm?d -- <br />- ? <br />-? <br />\ Lk C- In assure th ti quali ied 1-onoel properly gather and r,ahw a it. mformatiMt <br />bmitted <br />s <br />R <br />sed o <br />i <br />f <br />h l- <br />- <br />% <br />? u <br />. <br />a <br />n mt myu <br />n o <br />t <br />e per on or Persons who matwW the %i%tcm, <br /> or th:nr persons direetlp -po-ihie for gathering the mrormalion. the information -- t <br /> submitted is, to the beat .,f m% ktwiw led •r and belief. true, accurate. and complete. L: ; <br />S I <br /> <br /> <br />I um aw ur <br />th <br />t th <br />i <br />m <br />ifi <br />l <br />i <br />f <br />i <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />J <br />J 1 <br />TYPED OR PRINTED <br />r"rl&SAMI \1T0 w veil wwtwr1-1 rs e- w r <br />a <br />ere are <br />gn <br />ca <br />pena <br />t <br />es <br />ur snbm <br />lting fake infurmathnt, <br />including the possibilite ,d fine and imprisonment fur knowing Ootations, <br />.. .. .. . OFFICER OR AUTHORIZED AGENT LAREA <br />NUMBER <br />QODE YEAR MO DAY <br />`3ET7'L.EA'{LIE 300 iLlJ L IM, ' r b,I=LL <br />GR'fRL.Y fif1Fi .ItVG 1NSTRk)CT101\ <br />=P.4 Form 3320-1 (Rev. 3/99) Previous editions may be used. 0007 T is i"; a 4-part fonn.