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PERMITTEE NAM E/ADORESS, Include Faeilig AtimelLocarion if lhfferenf, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />ENGIN E <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 SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />1 ' <br />f i2 A -p, <br />c <br /> MEASUREMENT _ c <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 r <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif% under pen kh of law that this document and all attachments wtre _ TELEPHONE DATE <br /> a,cd unlrr - direction or v <br />re <br />-ision in aiivordonce with a system desi <br />ned ?----? <br />_ <br />- -• p <br />p <br />ul <br />g <br />to assure that qualified personnel properly gather and evaluate the information <br />h <br />i <br />B <br />d __ _ <br />1 ' `? <br />- _ %u <br />m <br />tim. <br />ase <br />nn my motion of the person or perwm who manage the system. - <br />-- <br />- .or those penom dir-t1, reslx,nsihlr for gathering the information. the inrormation <br />- - _ L - suhmitted is. Ito the I-t of mi knowledge and lx•lu•f. true. accurate, arid complete. <br />w•nalties fur submittin <br />faire information <br />I um aware that them arc si <br />nifl<vm <br />SIGNATURE OF PRINCIPAL EXECUTIVE ?- <br /> <br /> <br />PRINTED <br />TYPED OR g <br />I <br />g <br />, <br />including the pocsibitity of fine and imp' risonment for knrowm <br />g siolatiun+_ <br /> <br />OFFICER OR AUTHORIZED AGENT ARA <br /> <br />NUMBER <br /> <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. Thiti is 'a 4-0art f6mi.