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PERMITTEE NAME/ADDRESS ilnelude Fariliiq.%amraoratron ijbrflerrra <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <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 />Mir <br />(St <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> EX 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 ,. tl r•,: <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER certif. under, panalt) ,d taw that this document and all allachmems wen <br />red <br />nd <br />ti <br />i <br />di <br />i <br />i <br />d <br />t TELEPHONE DATE <br /> prepa <br />u <br />er m7 <br />on (it nupers <br />n accor <br />rec <br />s <br />on <br />ance wi <br />h a %)stem designed <br /> tow-wra that qualifiied perscmnd properl% gather and esaluate the information <br /> submitted. Bawd on m% inyuin of the prnon or perwms who manage the system. <br /> or Ih,- Its•rsons dir ctH reslamsible for gathering the information. the information <br /> submitted is. to the 1-1 of m? km,wledge and tw•tier. true. accurate, and complete. <br />I am aware that then are signirtc-ant <br />enalties for W-ming false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED p <br />. <br />including the lat ihilits or rive and imprisonment fur knowing siolations. OFFICER OR AUTHORIZED AGENT AREA <br />D NUMBER <br />YEAR <br />MO <br />DAY <br />ANU IZAF'LANA I IUN OF ANY <br />(Hererence an attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. "Thus is a 4-part form.