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PERMITTEE NAME/ADDRESS alnrlude FacitUY :1amelloealion if Uifferenty <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPOES) <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 />Form Approved <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <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 /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ) .' .- <br /> REQUIREMENT L' .' . <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certifI i under fx•null. of luw that this ducurnent and all attachments wore <br />i <br />d TELEPHONE DATE <br /> Prepared under - dirrelion tor supre,isinn in accordance with a sy tem des <br />gne <br /> to assurr that qualified personnel prula•rh gather and esalwta the information <br /> submitted. Hasrd on ny inquiry of the person or persons who manage the system. <br /> or thosr per oM dire<lly re+pemsible for gathering the inromiation, the informatinn <br /> erhmitted is. in the brst of nn knowicdgr and belief. true, accurate. and compkie. <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I um aearr that there are significant penalties for suhmitting false in <br />ormat <br />on. <br />including the ptnsibilih of rive and imprisunment for knowing siulatitms. <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference an attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.