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PERMITTEE NAME/ADDRESS(1 eAkF«+xryNa.?L on uD($Wv,") <br />NAME <br />ADDRESS <br />FACILITY j <br />LOCATION -iE <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (IWPOES/ <br />DISCHARGE MONITORING REPORT (DMR) <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 Inatrucdorn befwa completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX f11EOUENCV <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 />AME/TiTLE PRINCIPAL EXECUTIVE OFFICER I «rt'ty under penalty ° Is" that thh d-n,wnt and au auacha-nts arre TELEPHONE DATE <br />prepared ander my direetlon or mpee.Mon In accordance with a system des+tned <br />N <br />to amsrre that "*Nfied personnel properly talhee and evaluate the Inf°rnlatlon <br />sobmllled. Band on my IngYlry of the person ne persons who rnanate lhr system, <br />or those penom directly tvpordble fa tethering the Inro tlon, the Informellon <br />aubmllted I; to the best of my lk m kdte and belief, Ime, securest, and complete. <br />SIONATURE OF PRINCIPAL EXECUTNE . <br /> I am •"are that there art sstnlficaal penattin for mbmlttint War Informadon. AREA <br />TYPED OR PRINTED Includlnt the "ItINy of fine and lmprt.onn rnt for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference sN attachments hare) <br />T F CLAIM A P P R FA. -l 1-r! 'Y W (I-,: P <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a.4-part form. PAGE OF