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PERMITTEE NAME/ADDRESS ; lnrludr [a, din Namr/h limn if ixffereaq <br />NAME <br />ADDRESS .a <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 I -f <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 SAMPLE <br /> OF TYPE <br /> EX ALYSIS <br />AN <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />F <br />J`,1 i ?I <br /> MEASUREMENT I . <br />x PERMIT ?:. 1. Li _, rt•:,,.. <br /> REQUIREMENT <br /> SAMPLE -, <br /> MEASUREMENT <br /> PERMIT = <br /> REQUIREMENT 11;jr '! T+'- <br /> SAMPLE <br />MEASUREMENT <br />r I <br />` )?C? <br />1' '?? <br /> PERMIT _ tt L) 'n W :: e. l .. <br /> REQUIREMENT ^ IMONTH <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT Ot= IL.Y " 'IT"I <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i'., ' ' . 111'•i'. 'I I <br /> SAMPLE <br />J? <br />? <br />r A <br /> MEASUREMENT ? <br />t <br /> PERMIT .. . _ <br /> REQUIREMENT Off' ' T <br /> SAMPLE <br /> MEASUREMENT I C' `' 1 ?' / ! 1, l.'?? <br /> PERMIT 7 . . . r _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certir? under penalh ur law that this th untent and all attachments were <br /> <br />di <br />ti <br />lo <br />d <br />d <br />i <br />i <br />d <br />I <br /> <br />' <br /> <br />TELEPHONE <br /> <br />DATE <br />_ prepare <br />un <br />er my <br />rec <br />on or suPe• <br />on <br />n aceurdame• w <br />th it -tern <br />esigned <br />In assure that qualified P-innel proper1% gather and esaltwte the infurmatinn ' -- <br /> <br />- <br />itt <br />b <br />d <br />B <br />d <br />i <br />i <br />h _ <br />` su <br />e <br />ase <br />re of t <br />m <br />. <br />in ms <br />nqu <br />e prraiu or prranm who manage the scslem <br /> or those persons directh rry>.msible fur gathering the information, the information - / <br /> <br />submineel is, to the 1-1 of m) Gnowledgr and helnef. inte. accurate, and cumplete <br /> <br />1 - , 1 1 <br /> I am ass arc Ohm there are sigmrtcant Penalties for submitting false inforrttathm SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />including the l nssihilit? of fine and imprisonment far Amewing siolation, OFFICER OR AUTHORIZED AGENT <br />' AREA NUMBER <br />CODE YEAR MO DAY <br />AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. -