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PERMITTEE NAMEiADDRESS thteW, PbcilrA' NameiLxntion iJDirenr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR FROM MO DAY TO YEAR MO DAY <br /> <br />NOTE Read Instructions before comDletinq this form. <br />PARAMETER QUANTITY OR LOADING 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 />F 'A <br />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 />I <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 certify under penalty of law that thu document and all attachments were <br />d <br />d <br />d <br />t <br />i <br />i <br />i <br />d <br />i <br />h <br />h' <br />d <br />t <br />d TELEPHONE DATE <br />tin <br />irec <br />ion or superv <br />n accor <br />prepare <br />er my <br />s <br />on <br />ance w <br />t <br />a srh <br />m <br />e? <br />gnc <br />to assure that qualified personnel properly gather and evaluate the information <br />submitted. Ba ed on my inquiry of the person or Persons who manage the system. <br />_i or thole pe corks, directly relponslhle for gathering the information. the mfonnanl,n <br /> ubmin d is, to the"or my knowledge and helief, true, accurate, and complete <br />I am aware tluu there are significant penalties fur submitting falx information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />mchxling the Pnssibihfy of fine and imprisonment for knowin <br />siolations OFFICER OR AUTHORIZED AGENT ARE <br />NUMBER A <br />YEAR <br />MO <br />DAY <br /> g <br />. CODE <br />GUMMtN I, Anti tAVLANAI lure ur ANT vruL.AI lung (?tererence an arracnmenrs nere) <br />R P?EC] <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. r?i?C- 7 This . 1S a 4-part form.