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PERMITTEE NAME/ADDRESS rlnrlude Facilir L),lremnr) <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 k-l TO <br />Form Approved. <br />OMB No. 2040-0004 <br />( rjl <br />F <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREDUEN Y <br />SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t H 1:P OR 1" 70, AB <br />- REQUIREMENT V T' 7-1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t R AE F' <br />- <br />- - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT „ . 7 <br />1c F• REQUIREMENT - <br /> SAMPLE <br />?t• ,- MEASUREMENT <br /> PERMIT a T _ . ;'. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -+. 17R KEF'DF:} .. - :,=, .. <br />c FCC. J,;. REQUIREMENT J M; <br /> SAMPLE r lr ,. . <br /> MEASUREMENT <br /> PERMIT FR EP OR T F!--, <br /> REQUIREMENT ; ... ,`' t '•! M?; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccrnf} under penalty of law that IN, document and all attachments were TELEPHONE DATE <br />l _ prepared under my direction or supervision in accordance with a system dcsitne l <br /> <br />- to assure that qualified personnel propalt gather and evaluate the information - <br />' <br /> submitted. 13ascd on my inquiry of the pervm or perwns who manage the system, - -"' <br />-? or those perw?ns directly responsible for gathenng the information. the mf rmawm <br /> submitted is. to the best of my knowledge and hehct. true, accurate, and complete <br />ch <br />t th <br />r <br />i <br />lti <br />!* <br />I <br />ifi <br />t <br />b <br />f <br />l <br />f SIGNATURE OF PRINCIPAL EXECUTIVE ) ,' 3 <br /> am aware <br />a <br />ere a <br />c s <br />gn <br />pena <br />e, <br />w s i <br />can <br />mutnng <br />ormation. <br />a <br />se in <br />OFFICER OR A <br />T <br />O <br />I <br />E <br />TYPEDOR PRINTED mcludmg the pussthilm of tine and impn,ornicni !,,r wm,wmg s,olations, U <br />H <br />R <br />Z <br />D AGENT CODE NUMBER YEAR MO DAY <br />an aaacnments nere/ <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. 0041 , This isa 4-part form.