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PERMITTEE NAME/ADDRESS (in<du, 1. 1:n <br />NAME <br />ADDRESS <br />I FF <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 /> <br />?I <br />KInTC. 0-4 I..n•.....•t..... I...r .....:....:..t...t.... •?.Ic r.,.... <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAM"TLE PRINCIPAL EXECUTIVE OFFICER 1, caw, under penalty of law that thi% document and all attachments were <br />TELEPHONE <br />DATE <br />_ pr,pa cd under ms dtrrction or super. imon in accordance with a y:stcm designed <br />? ,. ;'> lL ?Lf?IS -f ?,_ 1O assure that yuaiiticd pcrormcl properly gather and esa luatc the imbrmatton <br /> submutcd Baud on my mymn of the person or pcr..ons who manage the system, <br />r - or those persons directly responsible for gathering the information, the mfontration -- <br />( • ; uhmin,d is, w the hest of my knowledge and belief, true, accurate, and complete. <br />h <br />h <br />i <br />fi SIGNATURE OF PRINCIPAL EXECUTIVE <br />' ' ? <br />!• <br />l <br /> a,-rc t <br />at t <br />ere arc s <br />gni <br />cant penalties for submitting fare Inlnmlaiwn. • <br />"'' ? <br />TYPED OR PRINTED the r.,whihte of fine and mlpn-nment for knowing, iolaion, OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> <br />4HR PR] <br />SAMPt <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This ii 'a 4-part form.