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PERMITTEE NAME/ADDRESS (Include FuJitr .4'onrr/L cuG n i Afprutl i NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />(Sl <br /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <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 <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif% under penalty of law that this document and all attachments were <br />anv) u <br />r <br />d <br />nn dir <br />ti <br />si <br />i <br />i <br />d <br />i <br />h TELEPHONE DATE <br /> pr <br />p <br />n <br />er <br />ec <br />on or super <br />on <br />s <br />n accor <br />"er w <br />t <br />a systrm d-igned <br /> In assure that quafified personnel property gather and elalttate the information <br /> submitted. B-d on my inquiry of the person or fw•rsons who manage the -tem. <br /> or those persons direetli restamsible for gathering the inrormation. the information <br /> submitted is. to the best of my knowledge and Wier. true. accurate, and complete. <br />I am aware that there are significant penalties for submitting false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />Imbaling the pnsihililt of fine and imprisonment for knowing siulations. <br />OFFICER OR AUTHORIZED AGENT AREA <br /> <br /> <br />NUMBER <br />CODE <br /> <br /> <br />EAR <br /> <br /> <br />O <br /> <br /> <br />AY <br />5 AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.