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PERMITTEE NAMEIADDRESS Nnclude FaciWY A'amelbvation if 1h1jereno <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certifi under penalu of law that Ihrs d-unleni and all allm$Invitt% werr <br />rdance with a <br />sl <br />d <br />d <br />r <br />di <br />ecti <br />r <br />u <br />rni4i <br />n in acc <br />de k <br />rd <br />z TELEPHONE DATE <br /> prepare <br />un <br />my <br />r <br />on o <br />% <br />p <br />u <br />o <br />g <br />rm <br />n <br />e <br />i <br /> to aasurr that qualified pe-1 properly gather and e%alunte the information <br /> cuhmitted. Raid on m% ingnin of the person or (a•nom who mmraRe the system. <br /> or lh- person dimilq mwmihte for gathering the informalimi. the information <br /> submitted is, to the heht of my knowledge and helief.live. accurate, and cnmpkte. <br />b <br />it <br />l <br />h <br />i <br />if <br />l <br />i <br />i <br />f <br />i <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />I rre . r, <br />se <br />on. <br />I am awarr that I <br />gn <br />icant prna <br />t <br />o for su <br />m <br />t <br />ng <br />a <br />nformat <br />inflating the pn..lhihly .,I fine and imprisnnmrnt for knnwing ciolatiom. <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />CO <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3.199) Previous a dons may be used. This is 3 4-Pali form.