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PERMITTEE NAME)ADDRESS,7."F.,o,,Af....,L«.r/enUo10.?1 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OiSCHAROE ELIMINATION SYSTUA /rNPOES) <br />DISCHARGE MONITORING REPORT IOMR) <br />PERMIT NUMBER o+SCHAaoE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Reed kietrucdone before complet" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX of <br /> 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 /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />1 rerwrt y under Pena ty o .w that thh doevmenl and .A .Ituchmrnts .ere T <br />TELEPHONE <br />NAMElT1TLE PRINCIPAL EXECUTIVE OFFICER <br />DATE <br />Prepared under my direction or superehlon In aerord.nce .lth a system designed <br />- le assure that quanned personnel property gather and e.aiu.te the inrormallon <br />. <br />submltled. Board on my Inquiry of the Person or Persons who manage the system, <br />or [hour persons directly respordb* for gathering the Informstle., the Information <br />/ submilted Is. to the best of my km-Wte and belief. trod. occurte..nd compkte. <br />I am aware that there ¦m ol <br />nlnunt <br />enalties for tubmilti <br />fals <br />Inf <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />ti <br />n <br /> g <br />P <br />ng <br />e <br />orma <br />o <br />. <br />TYPED OR PRINTIED Inrhding IM psnslblety or n.e and Imprisonment for knowing .telatlorst OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference eH attachments hers) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used THIS is a 4-parl form. PAGE OF