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PERMITTEE NAME/ADORESS (-*,* F-Wiy No.?L«.tten tfD(06w ) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (/NPDESI <br />DISCHARGE MONITORING REPORT (DA4R) <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 ImtrvcdoE» before comploOng We tam. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. F'REOUENCY SAMPLE <br /> EX OF <br />OF <br />Y <br /> AN <br />S PE <br />T <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 />t mrttly under Pena ty o law that thh dorriment and JI allachmenU were <br />TELEPHONE <br />NAMEfnTLE PRINCIPAL EXECUTTVE OFFICER <br />DATE <br />Prepared under my direction or superHslow In accordance with a syatennn designed <br />to aaure I%N qpuaNfled personnel properly gather and ee Jude the Inrnrmation <br />submlltnd. eased on my Inquiry o (the person or pt more who manage the system, <br />a thane persono directly retpordble Inc gathering the Infornatbn• Ike Info. tlon <br />.'? submitted K to the best of my knowledge and belief. Imc, accurate. and complete. <br />" I am aware that there are si <br />nlfkant <br />hl <br />fate I <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />- <br />fo <br />b <br />rltin <br />tk <br />f - ' <br /> g <br />p <br />s <br />r m <br />n <br />g <br />n <br />orma <br />es <br />m. AREA <br />TYPED OR PRINTED Including the poarbtuty of Mm and Imprisonment red knowing .ldadom OFFICER OR AUTHORIZED AGENT ODE NUMBER <br />C YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference dt attachments herel <br />r- rt pTM .rtftr,-nt-?"? C+?. ,.•..,? <br />EPA Form 3320-1 (Rev 3M) Previous editions may be used This is a 4-part form. PAGE OF