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PERMITTEE NAMEIADDRESS ilnclude Fardirr \amrwl ,,, w o if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <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 2040-00(j.1 <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 I <br />l? <br />V1 <br /> MEASUREMENT - <br /> <br />PERMIT <br />14 ILI 777 <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 crrtts under Ienall> or law that thi, document and all attachmrnl% arrr 1 TELEPHONE DATE <br /> Prepared under me direction ur wpen won in accordance with . s-trm dc.igncd _ ; <br />? <br /> <br />J to a ere that qualified pervannel propene gather and realuatr the inrormaUuw • <br />__? <br />! _ _. <br />f - +uhwniti d. R-d on m% inquin of thr Zenon or per on+ who manage the -tern. - <br /> or thaw lemons dirtmlh reaponcihk for gathering the Information, the inrorntation <br /> hmimd i, to the twat of m% knowirdxv and heifer <br />true <br />accurate <br />and com <br />kh• <br />% I j <br /> . <br />. <br />. <br />, <br />p <br />u <br />i <br />r SIGNATURE OF PRINCIPAL EXECUTIVE <br /> n <br />ormalion. <br />I am aware that iherr are %ignificant pendtie, for %ubmitting rake <br />FFI <br />ER OR A <br />TH <br />RIZED AGENT AREA <br />TYPED OR PRINTED including the p-ibilit% of fine and impriconrm•nt ror knowinK.Hdulow, O <br />C <br />U <br />O ODE NUMBER YEAR MO DA <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This i& A 4-part-form.