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PERMITTEE NAMEIADDRESS (include Fdcilirr .? mr l a;um it Pill-n! <br />r <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 />OMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREOUENCY SAMPLE <br /> OF <br />TYPE <br /> EX 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 />NAMErrITLE PRINCIPAL EXECUTIVE OFFICER I cenif, uu I- Innate) of luw that this doc•unrent and all attadmtenth wrm I e- _-} TELEPHONE DATE <br />_ prrparad under nn dirn•tiun or wpeni.ion in urrordance with a s-tam deigned -? <br />;` ;,- r't; t <br /> <br />--> V (. - <br />t In assure that I <br />n uabrird p'r,onnel ProPcrtv aalter and eruluute the information <br /> <br />I I <br />, <br />- suhmitl,d. R-d on my inyuir. of the per+on or prrvan who manage the .'.tern, - --, <br />` <br />/ or th,.w- Pons dirrctl% rmp ohir for gathering the information, the information -; <br />V <br />.. ubmitted is. to the IN.t or nn kn,,. Wl r and belief. Iru, accurate. and compktr. J <br />- <br /> 1 am aware (hat there are si <br />n irn <br />for suh <br />a <br />t <br />altie <br />itti <br />r <br />i <br />l <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE - ' <br />TYPED OR PRINTED g <br />c <br />n <br />Pen <br />, <br />m <br />ng <br />n <br />urtnat <br />u <br />e <br />,m. <br />including the p».ihility of fine and impriumment for knowing .i,datkms OFRCER OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br /> D <br />S AND tAVLANAIION OF ANY VIOLATIONS (Reference all attachments here) <br />6PA Form 3320-1 (Rev. 3199) Previous editions may be used. 'n1i% iS a 4-part fOml.