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PERMITTEE NAME/ADDRESS tincrwlr Pu u,: ;rcrcnq <br />NAME <br />ADDRESS I( <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 +??- <br />FROM <br />1 -l TO <br />rm Ap proved. <br />FoM <br />B No. 2040-0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. FREDUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. ,C <br />V .,i .. ?Li .. REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />i r 7 J REQUIREMENT hl ? <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT ]n17 1'\, . <br /> REQUIREMENT C' !=N T <br /> SAMPLE <br />HRU i', = '' l•i i ! _.' ` MEASUREMENT <br />r. PERMIT R. -:t91#4 2t-if,r 'i ?-?s <br /> REQUIREMENT (. r •'.i rl <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ?cmh under penalty of Lm that this dot:umcm and all anachment. were <br />r TELEPHONE DATE <br /> <br />/ it! prcpar <br />d undo m7 dtrcvtwn or supenlsion in accordance with a s1. tem designed <br />to assure that qualified personnel properly gather and evaluate the int ,rmauon <br /> <br />l <br /> -submitted. Based on m) i ury of the person or persons who mans the system, ?•??./? f?? <br />'/•' , _ OT thoaE persons dlreClll' r'SIM)IImbiC for gathering the tnformjuof the information <br /> 9ubm,ucd is, to the best of my knowledge and belief <br />true <br />accurate <br />and complete <br /> . <br />, <br />, <br />ar: d,:I: Ihwre are significant penalties for submitting fake mfamuuon SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPEDOR PRINTED . <br />inch, i:z of fine amt imprisonment for knowing %IOlmtcros. OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />aA PIP; <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 0 24 This is_a 4-part form.