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PERMITTEE NAME/ADDRESS (I.A.& rMryN?.?Ler«lon (/n(?i...r) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT WMR) <br />PERMIT NUMBER DISCHAIIOE 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 frntfuctlom Wore compMtinO this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREOUENCY <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 />NAMErnnE PRINCIPAL EXECUTIVE OFFICER t "may r r "Pt-hr o law that thb doeoment and all attachments were <br />TELEPHONE <br />DATE <br />prepared ruder my dlrrllon or fupersktlon In accordance with • system designed <br />to afsrre that 9-14fled prrsonnel property galber and eraluatr the Information <br />aobmllted. !ad mm my inquiry of the person ne persons who m anste the fyflrm. <br />or those persons directly refpordble for gathering the Information. the Informatlon <br />w bmllted Is. to the best of my knowledge and beMef, true, accurate, and complete. <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />i <br /> I am swam that there are s <br />gnificant prnaltks for sobmltting fabe Infornstfon, <br />TYPED OR PRINTED Including thepossibility of fine and ImprlfonmentFor knowing .Wsdon& OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reforonce ntt attachments hors/ <br />This is a 4-pan form. PAGE OF <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used.