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FERMITTEE NAME/ADDRESS (--6&Forikry Nss a?Loratton f/DIQlwwrq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM (NPDES/ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHAAOE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Fofm Approved. <br />OMS No 2040-0004 <br />NOTE: Read Imtruetione 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 /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />S <br />M <br />NT <br /> MEA <br />URE <br />E <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br />'j <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />I nnny u r pena ty a ow that this dotntnent and all attachments were T <br />TELEPHONE <br />NAMElT1TLE PRINCIPAL EXECUTIVE OFFICER <br />DATE <br />prepared under my di rilon or mpersifon In accordance with a system designed <br />i to .ours that quehlled personnel properly Pther and evaluate the Inforwa llon <br />s.bmllwd. Based on my Irputry of the pavan or P-,sons who manage the system, - <br />tl <br />tbi <br />th <br />i <br />d <br />f <br />I <br />y mpons <br />or ga <br />or those persons <br />irec <br />e <br />er <br />ng Che Inforwtatim, the <br />nformation <br />• , ' f ?` mbrni tied b. to the beef of my knowledte and better. feve, arevnte. and remPhrie. <br />ifi <br />SIGNATURE OF PRtNCWAL EXECUTIVE - <br />i <br />t <br />l <br />l <br /> I am aware Chat there are s <br />gn <br />can <br />pmaftla for mbm <br />ttfnt fa <br />se Information. A AN <br />TYPED OR PRINTED IndWint 0w poadbluty of nns and Imprbonmeet for knowing rlolaU&ro. OFFICER OR AUTHORIZED AGENT CODE NUMSER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY <br />off •ffocnmenfs Aoro/ <br />EPA Form 3320.1 (Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF