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PERMITTEE NAMEiADDRESS rh%lade Facility Nane.'Localum IfDiffemnl/ <br />NAME <br />ADDRESS J <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. 2040-0GC4 <br />DCUT TO RELY <br />MITE, Rnarl In¢}rur}i- hn/nun nn.....Infinn }trio trim <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREDUENCY SAMPLE <br /> OF <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE T <br />? MEASUREMENT <br /> PERMIT r. .i r. > . <br />i 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 remit} under penah} .d laN that this dcwutnent and all attachments were TELEPHONE DATE <br /> prepared under my doa non or supcn ision an accordance with a system designed <br /> 'o assure that qualified personnel properly gathcr and csaluate the information <br />? ' - uhmitted. Fiascd on my myuirv of the person or perms K. manage the sy-stem, <br /> or those person dlrccllY responsible for g'athenng the information. the information <br />L submitted is. to the best of my knowledge and Ixltef. to c, accurate. ,nd complete <br />h <br />h <br />f <br />l <br />b SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware t <br />at t <br />ere are smgni <br />tcant pena <br />ties for su <br />matmng false information <br /> <br />TYPED OR PRINTED <br />........?..?.. ..... ...._. ... __._.. __ ........_. <br />ineludn • the possibility of fine and imprisonrnent for knowing siolaftons. <br />_....._b._ - .. .. . - OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />- <br />DAY <br />I'Vf C/ <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />D FOR 10YF,G4HR PRE <br />! 3. W I-K -Y SAMPL.1 <br />_ bis !S a --part form.