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ADDRESS <br />FACILITY <br />LOCATION <br />., ,.,fir ..• P I) i .u;:. .... ::. <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER j y r- I.? pi's <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO }L <br />NOTF- Raa(f Inctrimlinna hafnra emm?latinn thic form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT # r ' + <br />v- , r t - J • . , REQUIREMENT <br />30 DA <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c.• : t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />F t v r'.! r REQUIREMENT i t Y <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r ; <br />C_ ? r <br /> SAMPLE <br />,- ' : _• r :. MEASUREMENT <br /> PERMIT r - . ,• <br />-? REQUIREMENT <br />i' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :•r; sc <br /> REQUIREMENT ,. •.? TR A! <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif. under penalty of law that this do.:umem and all attachment, were TELEPHONE DATE <br />_ prelrwed under my direction or supen-Lain m accordance wuh a system &-signed <br /> to aasure that qualificef personnel properly gather and c,31uate the mfornwnon <br /> submitted. Based on m) urqurr. of the person or persons who manage the .}stem. <br />i . - or those persons directly responsible for gathering the information, the information <br />L submitted is. to the best of my knowledge and belief <br />accurate <br />true <br />and complete ? <br /> , <br />, <br />. <br />I <br />h <br />h <br />l <br />f <br />b <br />l SIGNATURE OF PRINCIPAL EXECUTIVE <br />jiJ <br />'- <br /> <br />- <br />TYPED OR PRINTED am aware t <br />at t <br />ere are significant pena <br />uas <br />or su <br />mitting fa <br />se information. <br />including the lwssib,hn of fine tad tmprisonmcnt for knowing .relations OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> . <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used- <br />aI1 aIIG VII/IICII[J IIC/Cf <br />i-IR !RE( <br />-?kMPL I I <br />This is a 4-part form.