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PERMITTEE NAME/ADDRESS p.d.4 F«uuy v wL«rmn l/atf. nq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NMES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO L_ I <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read IF»tructiwa before compMtlnp this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />Ex FREQUENCY <br />OF SAMPLE <br /> <br />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 /> 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 />NAMEfME PRINCIPAL EXECUTIVE OFFICER I n^'1. V M- penalty ° I" that th" dorolnrnl and all •tlarhlrlrtra were TELEPHONE DATE <br />prepared and- my dlreell n or suprr'e1sion In amordanre with a system designed <br />r to aeon that quahned personnel propeely Sather and rrahralr IM Infnemallon <br />F: / ,- l r ; r sabmltted. Bred on my inquiry of thr pen°n or person who manage the system. <br />_ <br />or those persons dirertty mpoldble for gathering the Information, the Information ' <br />r. _ mbmllled is, to the best of my knowledge and hither. Irne. atevmlr. and romplele. <br />r 1 am .wart that then an lion and <br />rna7tla f <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />bmittin <br />f <br />l <br />I <br />f <br />tio <br />TYPED OR PRINTED p <br />or su <br />g <br />a <br />a <br />n <br />orma <br />n. <br />lorludlnS the poadbnlty of mar and Imprisonment for knowing eiolatlon . OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference i)It attachments her*) <br />EPA Form 3320.1 (Rev 3/99) Previous editions may be used This is a 4-part form. PAGE OF