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PEAMITTEE NAMEIADDRESS nlnclude Farilin 4rrnn'Llln:rr.,n :J oiQ•rrn: <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY <br />FROM TO YEAR MO DAY <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 />E OF <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I .rrtifs under prnalts of laN that this document and all altachments Nrre { <br />i <br />TELEPHONE <br />DATE <br /> prepared under Ins directilm !Ir +llp\•rstilm in accordance Nith a system de.iRMA _ <br />- <br />r <br />- Ia nsmre thug \ ualined monnel Iro rl\ Rather and c\:daatr the information ??-- --?-_ - <br />- ) submitted. Ilasetl on ms intluin !If Illy p\'nlln Ile (M'rNn1? Nho manage tlgesystem. - - - <br /> or thaw lwm,ms directll responsible for Fathering the inforntation, the inrormation <br /> submitIM is. to the Ist of Ins knoNledge and tAirl. we, accurate, and co npolor. <br /> I.. assure thug ther <br />rc si <br />ifc <br />n <br />lti <br />b <br />i <br />s f <br />itti <br />f <br />l <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED e a <br />u <br />pena <br />or su <br />ng <br />se <br />n <br />orma <br />gn <br />e <br />m <br />a <br />on. <br />including Iln• pnasibilits of tine and imprisomnrnt for knossing %iolationc. OFFICER OR AUTHORIZED AGENT AREA <br /> <br />NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />I+VMMCIY 1 a AIYL/ CJIr'LAIYA I IVIV Vr AN T v1VLA 11VfVA Irreverence ail affacnmenfs nere) <br />EPA Fcrm 3320-' Re, 3 99, Previous editions may be used This is a 4-part form. PAGE OF