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PERMITTEE NAME/ADDRESS tl w/wk FncilUv Nwnc/Location rjDiff mnr/ <br />NAME r .... <br />ADDRESS i!- <br />FACILITY <br />LOCATION <br />LIt L <br />tr.1 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />I3l_AN <br />k <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />EX Of <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />_ MEASUREMENT <br /> PERMIT I;?:+" r 7f?l_" RA! <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = et ifi a UP"! <br /> REQUIREMENT y r?l> <br />c SAMPLE <br />" MEASUREMENT <br /> PERMIT * > .. ?x -:- F - <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 cenif: under penalty of law that this document and all attachments were <br />d TELEPHONE DATE <br /> prepare <br />under my direction or supcnision in accordance with it .. v.item designed <br />SrG?! to assure that qualified personnel properly gather and evaluate the information _ -- <br />`? <br />- submitted. Based on m} inquiry of the person or persons who manage the system. ?f .• " ?' ' <br />l <br />" or those persons ducal} responsible for gathering the information. the infomation R <br />' • - - <br />?: a r submitted ts, to the best of my knowledge and belief, mle, accurate. and a+mplele <br />I am aware that th <br />r <br />re <br />nif <br />a <br />t <br />lt <br />f <br />b <br />tt <br />f <br />l _ _ <br />SIGNATURE OF PRINCIPAL EXECUTIVE ! <br />, <br />TYPECS OR PRINTED e a <br />sig <br />ic <br />pena <br />or su <br />se inn nn n' n. <br />e <br />n <br />ies <br />mi <br />ing <br />a <br />MhIdICg the posslhiht} of fine and imprisonment I?,r knuHmg vml.n;„ i , OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> CODE <br />VuMMtrv I, ANU tArwrvAI Ivry yr AnT vtvual lvna (rrererence an arracnmenrs nere) <br /> <br />EPA Form 3320-1 (Rec. 3139) Previous Editions may be used. his 1S a 4-part form. PAGE OF