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PERMITTEE NAME/ADDRESS (Include Facilitt Aamol- a ivoit if Pifferrnt <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br /> <br />OF <br />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 /> <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 1 certify under prnall? or law that this document and all attachment, wem TELEPHONE DATE <br /> prepared under tm direction or supervision in accnrdatwr with a system designed <br /> to a+curr that qualified prnnnnri properl's gather and eraluate the information <br /> submitted. Rased on m) inquire of the prmon or prr%om who manage the ystem. <br /> or those fwr.on% dlrecti? r<sfr,nsihle for gathering the information. the information <br /> submitted is, to the Mot of m% knowledge and belief. true. accurate. and romplrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I emt aware that there arc significant penaltit+ for .uhmitting false information. <br />t fo <br />owin <br />siolatinns <br />ihilit <br />ri <br />o <br />m <br />k <br />h <br />f f <br />d i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED . <br />e faxs <br />y o <br />ine an <br />mp <br />s <br />n <br />en <br />r <br />n <br />g <br />imluding t DE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />;T <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used.