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PERMITTEE NA ME)ADDRESS(7-o"Jr-M.NaaaWLe 11-i/D( Wuw) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINAT10N SYSTDA /NPOES) <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 kwttucdotw before complat" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />YP <br /> ANALYSIS E <br />T <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER I centty • r penalty low that this tMcumeol and 1a atlachments were TELEPHONE DATE <br />prepared under my direcllon or supeevfalon In aceords- with • system ddtned <br />to aa,ure that qualified personteei property talker and evaluate the inrqmn lion <br />In bmilled. Based on my inquiry of the person or ptrwna who mansge be system, <br />' or those persons directly refpon9bk for gathering the Infor tlaa, the Information - <br />submitted k, to the best of my knowledge and belief. 1roe, amtratr. and complete. <br />- - - I sm aware that th <br />re are si <br />nificant <br />ttk <br />SIGNATURE OF PRINCIPAL EXECUTWE <br />m <br />f <br />ub <br />ittin <br />fatty inf <br />v <br />tl <br /> g <br />e <br />p <br />a <br />s <br />or s <br />m <br />g <br />or <br />sa <br />on, AREA <br />TYPED PRINTED Including the pouibmly of fine and imprisonment far knowing r+oiatkm& OFFICER 09 AUTHORIZED AGENT NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerrenc• aN •ftachmenfa hare) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This is a 4-Part fond. PAGE OF