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Frorm <br />FERMITTEE NAME/ADDRESS (-&&f rwryHa.?L.wati- (1D?irw1) NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM fNPDET) OMB NoP2040-0004 <br />NAME DISCHARGE MONITORING REPORT fOMR/ <br />ADDRESS <br />PERMIT NUMBER ascHAnOE NUMBER <br />MONITORING PERIOD <br />FACILITY - <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />NOTE: Read Instructlone bolos completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCV <br /> <br />F <br />SAMPLE <br /> EX O 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 /> <br />NAMEfTITLE PRINCIPAL EXECUTIVE OFFICER t mrmy under pen• q sw that this dorum l and au amrhmenu were TELEPHONE DATE <br />prepared under my dlrerllon or super.ldon In arcord- with a systeen desltned <br />to arurt that qualified person-4 property Lather and evaluate the Information <br />submitted. Baud on my inquiry of the person or persons who manage led system, <br />or thou pers ms directly msponslbk for gathering the Information, the lnfnrmalfnn <br />Submitted I& to the best or my knowledge and beBef. trw, accurate. and compklr. <br />n <br />SIONATURE OF PRINCWAL EXECUTT/E <br /> 1 am aware that there are slBM <br />r>tnt penalties for submitting robe Information, AREA <br />TYPED OR PRINTED Inchdlnt the podbluty of fine and Imprtsanment roc knowing vldatlores OFFICER OR AUTHORIZED AGENT ODE NUMBER <br />C YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Referanc• aB •ttachmonts hare/ <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used This is a 4-part form.