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PERMITTEE NAME/ADDRESS (7m&& F&,O#yNa.?Lx mi- t(D(P-1) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM ((NPDfS/ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER NSCHAIOE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Forth Approved <br />OMB No 2040-0004 <br />NOTE: Road Irntrvctlono before completing" form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO <br /> <br />. <br />OUENCr <br /> <br />OF <br /> <br />SAMPLE <br /> EX r 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 />MnE PRINCIPAL EXECUTIVE OFFICER ' certtly . penalty iaw that this docvtnrnt and an atnchmenu wen TELEPHONE <br />AME DATE <br />. <br />prepared mkr my dlrectlon or fupee.ldon In sccoedanm with a system designed <br />N <br />to - that quaNMd persannet properly gather and eeafuate the Infoemanon <br />_ submitted. Based on my ImC.1ry of the penoa or penoro who manate the tyttem, <br />or `hoes persons directly respondble for gathering the Infoemallon, the Inrormati n <br />mbrrdtted Is, to the best of my kno+rhedte and better, true, accuratw and mmplete. <br />RE OF PRINCWAL EXECUTIVE <br />I <br />NAT <br />T I am .than that then are dgninca.t pertains for submitting fatse information, s <br />O <br />LV AREA <br />TYPED OR PRINTED Including the po?lbiuty or Am and Immp rhonment for knowing elolatfom`s OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION Ur ANY VIVLA I IUN5 Irfererenc• am •rrwcnmenrs nerel <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan form