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PERMITTEE NAME)ADDRESS t)w h-&FartlfyNa-lLeeartew UOfF?•tN) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />iL <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTUA NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHMIGE 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 k»trucdorw before completing 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 />t nrLl) 0"""' pen- If *flow that t hh document and N ¦Ilachments were <br />TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER <br />DATE <br />prep-red.nder mf dlrecfbn or -pe,.1 - In a?ee.nn wun . system d.6gnea <br />to s-eun that guallned personnel prtgw f gather and e.Musle the Informatlon <br />-.bmttled. aseed .n my Inqulr7 or the person w persoty who -ate the fystem, <br />w thou per-ota directly respondble for gathering the Information, the Informallon <br />wbmllled K b The btlf of m] knewtedte .nd beMef, 1r , . rale. and complete. <br />I ¦m aw <br />th <br />t then are -I <br />Nftcanl <br />en-Ifle for -ubmHri <br />SIGNATURE OF PRINCIPAL EXECUTNE <br />f <br />t <br />I <br />l <br />r <br /> g <br />p <br />-n <br />a <br />ng <br />a <br />s <br />n <br />orm. <br />len, ARIE* <br />TYPED OR PRINTED Including the pomlbllllr or floc and Imprisonment for knowing .ioleul OFFICER OR AUTHORIZED AGENT ODE NUMEIER <br />C YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ad attachments hers/ <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used. This is a 4-pall form. PAGE