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PERMITTEE NAME/ADDRESS (include FarifitT Yamr I,,an,o, i(ftifferrnf, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT ::d I DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO I -f <br />Form Approved. <br />OMB No 2040-0004 <br />L IVHL. <br />iC WET TE-`7TIf'4G F <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• NCY <br />FREO <br />U SAMPLE <br /> EX O <br />F TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />M <br />7 I n / <br />/ xj <br /> EASUREMENT <br /> PERMIT - i1 L P (vR <br />F " . - <br /> REQUIREMENT ; I NGSAM' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :. ;• . a : , . F ` j"I <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 />f' t <br />/ <br /> MEASUREMENT I <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I r,rtif) tinder penalty or law that this document and all attachment% were <br />prepared under my direction or su <br />wrikion in accordance with a <br />sirm d"I <br />ned TELEPHONE DATE <br /> t <br />y <br />g <br /> <br />~ to assure that qualified pe-nnel proprric galhrr and rsatualr the information <br />- <br />-- <br /> <br /> <br />t submittal. Hasrd on nn inquire of [tic la,"in or pewees who manage the -tern, <br />? /y <br />? <br /> or thane pemons direct] responsihie ror gathering the informautat the information <br /> <br />• ?- uhrnitted is, to the bra of m? knowledge and hrlief. uue. accurate, and complete. <br />I ant aware th <br />ifi <br />t <br />alti <br />b <br />rnt <br />t th <br />a <br />si <br />r <br />fu <br />s <br />itti <br />f <br />lsr i <br />r <br />ti <br />n <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />'- '- <br />'- <br /> n <br />a <br />em <br />m <br />gn <br />can <br />lt <br />n <br />e, <br />r <br />u <br />m <br />ng <br />a <br />n <br />n <br />o <br />. OFFICER OR AUTHORIZED AGENT AR <br />J <br />TYPED OR PRINTED Imludiog the ju-ihilits or Fine and imprisonment for knowing eiolatisot, pE NUMBER <br />C YEAR MO DAY <br />t+UMMCIY i J MIYU CArLMIVM I IVIY Vr MIN T <br /> <br />InalererlGtl an attaG"mar"s "ere/ <br />FISTICALI_.Y SIGNIF DIFt; UETWI <br />EPA Form 3320-1 (Rev, 3/99) Previous editions may be used. This is a 4-part fon-n.