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PERMITTEE NAME/ADDRESS dnrlude Fn: ilia \um, 1. „ ,,- ;; f of -al <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. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE 1 <br /> MEASUREMENT <br /> • <br /> PERMIT - <br /> REQUIREMENT - ANNt!A <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i,i•' ter, . <br /> <br /> SAMPLE <br /> MEASUREMENT <br />9 <br />--1 <br /> <br />PERMIT 1 r <br />1 <br />- <br />i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />. <br /> MEASUREMENT 1 <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ; • ,. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - °-` <br />NAMErfITLE PRINCIPAL EXECUTIVE OFFICER I certify under pena11% of taw that uii%d-cement and all attachment% were TELEPHONE DATE <br />_ prepared umler my dimction or wpenWon in Ma urdance with a .'s+tem de.iRmd <br /> <br />r to x+wre that qualified pcn9nnd prnperh gather and etatuale the information <br />__--- <br />-'- G- , - - , ithmitted. Bawd nm m, inquiry of the perwn or lw nom who nwmtgr lM• s)stela <br />i or th:m.• penun, dir•tth -'ramm%ible fur gat1wring Ihr information. the information <br /> owled <br />d b <br />ttv <br />curate <br />and com <br />lete <br />itt <br />h <br />th <br />t <br />k <br />a <br />li <br />f <br />a <br />h <br />d I <br />b <br />f <br /> , <br />p <br />. <br />%, <br />i <br />e <br />o <br />m) <br />n <br />ge <br />n <br />e <br />, <br />e. <br />c <br />%u <br />m <br />t <br />es <br />e <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> Penalties fur.uhmwinR falw information, <br />I um aware that there a n <br />i <br />i <br />ti <br />f <br />k <br />i <br />l <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED and <br />now <br />u <br />ane. <br />including the prnabiliq o 4f <br />ne:mA impri.unment <br />or <br />ng c <br />a O <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />!L,'E ON THIS OUTFRALL. IF NO-( <br />rl'I.L.LY SCGI\IIF RIFF OFTWEIFN 1-' <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part fornl.