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PERMI[ TEE NAME/ADDRESS Ltrlude Farilits.\'ame'l,rum n q li,ffercm, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <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 i i L . <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 certih under penalq of No that this durum and all attachment% were <br />i <br />with <br />y <br />d <br />i <br />ed <br />d <br />d <br />di <br />ti <br />M <br />i <br />d <br />t TELEPHONE DATE <br /> on <br />n accor <br />ance <br />u s <br />s <br />em <br />es <br />gn <br />prepare <br />un <br />er m? <br />rec <br />on or supr <br />s <br /> to assure that qualified personnel pruperli gather and rsuhraic tlw- information <br /> submillod. Rased on my inquiry of the person or persons who menage the m tc•m. <br /> ur throe persons directly responsible for gathering the information, the information <br /> submittd is, to the best '(ml knowledge and belkL true, accurate. and complete. <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there are iignirtcunt penalties for submitting fake in <br />ormation. <br />Including the possibility of fine and imprisonment for knowing si,datioas OFFICER OR AUTHORIZED AGENT AREA <br /> <br /> <br />E NUMBER <br />COD <br /> <br /> <br />EAR <br /> <br /> <br />O <br /> <br /> <br />AY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments nere) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. This is d 4-Part form.