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I PERMITTEE NAME/ADDRESS (include Facilin- NanrriLocarion i/Uifjelen)1 <br />` NAME <br />I ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMR) <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 />i' <br />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING <br />I QUALITY OR CONCENTRATION <br />NO. <br />FREQUENCY <br />SAMPLE <br /> <br />E OF <br />E <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS X ANALYSIS TYP <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- - _ ; REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :. ,. _ <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT < c- <br />- - REQUIREMENT ?A ! !_ 7y, <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 cenify under penalty of law that this document and all attachments acre TELEPHONE <br /> <br />prepared under my direction or supcnision to accordance with it sy%tem designed DATE <br />_ <br />? '- <br />? <br />?• - to assure that qualified personnel properly gather and evaluate the ml'ormatnm <br />?-+ <br />? <br />- <br />- submitted. Based an my inquiry of the person or persons whn manage the systtm, <br /> or those pcrsans directly responsible for gathering the information. the information '- <br />J' <br />' -ub <br />m <br />t tut the hesd <br />and <br />lctc <br />l <br />I <br />? <br />t <br />m <br /> rc <br />- <br />- <br />n <br />it SIGNATURE Of15RINCIPAL EXECUTIVE - •- ? <br />- l <br />po• <br />l <br />i, <br />e am <br />f <br />su m <br />ring fal <br />x- <br />mi <br />ormtaticxt <br />tgnifi.ant -. <br />' •_ <br />_ TYPED <br />OR PRINTED dulny n(fmc and impr :, ,n,ri,t i, r ,:na amg su,lanons OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />CnMMENTC ANr) FXPI ANATION nF ANY vine ATlnNC /aafo.o.,, a art ?Ne, ti..,,.. • r, t <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. :I Thli is a .4-pan R)rnl.