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PERMITTEE NAME/ADDRESS Ilnrfudr FaeiA1y Namr.1-,m.m if Pof,rrnr <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 YEAR MO DAY <br />FROM TO <br />Form Approved. <br />,)MB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />7 1 <br />I'? <br /> MEASUREMENT <br /> <br />PERMIT <br />13{j` <br />i•r tFd? <br />{_,. <br />7- 7 <br />, <br /> REQUIREMENT r,t:-.` ra1,!?' .'•=ti .. <br /> SAMPLE I " - l ?f I I .. '? <br /> MEASUREMENT <br /> PERMIT . r - <br /> REQUIREMENT 1r4?..': ;=?1" `' <br /> SAMPLE <br /> MEASUREMENT J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />- <br /> <br />PERMIT <br />f' cfs O`ff' <br />,, 77 <br />7 <br /> REQUIREMENT PdtiSAMC <br /> SAMPLE _ <br />I^'^ / f <br />a. <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />7 I', / <br />IJ <br />?I r>? <br />C=?~ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cerUf% under Penalt, of law that this doevtmni and all atlachmmts were <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> prepared under my direction or supervision in wcordancr wil <br />u stem <br />es <br />gne <br /> to assure that qualified per-onmi prnfrrtl gather and evaluate the informathn ?---t - - <br />/ <br />41, submitted. Based on nn inyult of the {w•r, n or persons who manage the svstrnt. - --? '-_ <br />;? -. - <br />t or thine Persns dirtvti? rrsfa.rnible for gathering the information, the information _! -, -, - <br />• <br />_ <br />d Wi <br />t <br />lo <br />b <br />l <br />d <br />r <br />d <br />' <br />? ? <br />' <br />? <br />1 r <br />? <br /> <br />l ge an <br />e, an <br />comp <br />c. <br />submitted as. t,, I <br />e Irat or ms kno% <br />e <br />e <br />. true. accura - <br />SIGNATURE OF PRINCIPAL EXECUTIVE .- <br />: <br />, _ ? <br />_ . f ? <br />TYPED OR PRINTED 1 um aware that theft ire suunirecant Penalties rnr wlunewng false mf-w-t wu. <br />including the possdnlits or rim and imprivmment for Lowing violation,. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />L;QMMtrv I S ANU tAP'LANM I IVPI Vr Are T viwLA I IVt\J <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />t tct c/ <br />Thiti IS' a 4-part form.