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PERMITTEE NAME/ADDRESS'include F'ariGtr Namr/l-,fi, n if different' <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION V. - <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 I I f : <br />Form Approved <br />OMB No 2040-0004 <br />'-1.1 N;JH <br />SUBR _)C <br />F - FINAL. FOUT1 <br />?iIRFACE F`,-!W IFF 10 TRQU-T C-HEEV- <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 raj 1- ISv?ll_ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT :' Y (? ;r?T}• <br /> <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 />NAMEfrITLE PRINCIPAL EXECUTIVE OFFICER I crrtify under p•nalts „r law that thi, docuntrm and all attachment. weer - TELEPHONE DATE <br /> prepared under ms dire tion or surw-rri%ion in aecordann• with a system designed _ <br />:? <br />,• ? <br />?` ?• .. - .. --? ?- to asnvr thal qualified personnel properly gather and rsaluatc• the inrormation <br />submilld. Based on o,% inquire .(the person or per,an, wfio manugr the %v Irm. '-'?----- - - <br /> or those per,um direr ii% rnpin,ibir fur gathering the information. the information <br /> submitted i,, In the to-,t of m) Atwwledge and Wier. true, -urate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE ?-' . l 1. 'mot `` I f <br />TYPED OR PRINTED I am aware that there are significant penah" fur suhmitang false inf-uwtiun. <br />including the the ihihlt of Me and imp riu,n"mnm for knowing i lation. OFFICER OR AUTHORIZED AGENT AREDA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence an anacnmenrs nere) <br />F I a r>. P(: =i F(lk REGUIREMENT! <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. t• This is a 4-part form.