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PrHi,!!1.1 EE IIAFAE ADDRESS <br />tJL,.;':ie <br />ADDRESS <br />a <br />FACILITY <br />LOCATION C i <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 />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREQUENCY <br />SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x <br /> REQUIREMENT :'=IJK 1?/C <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t -"T REP (IF? T <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccmf? under pet>uln of law that this d„cuntent and all attachment, .,crv TELEPHONE DATE <br />_ p reparcd under m) direction or supers tsion in accordance with 4 ?5 stcm dcstKncd <br /> to as_surc that qualified personnel prupah gather and evaluate the intnrman,ut <br />- submitted. Based on my inyuin of the in-rson or persons who manaec the syActn, <br /> or those perwrts directly resix,nsible for gathering the information. the information - --??'L <br /> <br />' aubmittcd is, to the best of my knowledge and belief; true. accurate, and complete <br />I <br />u <br />th <br />t th <br />ifi <br />t <br />l <br />b <br />i <br />f <br />L SIGNATURE OF PRINCIPAL EXECUTIVE <br />[ '71 - ! <br />' <br /> . <br />n aware <br />a <br />ere arc sign <br />can <br />pena <br />es <br />mitting fa <br />se uttortnam,n. <br />t <br />or su <br />OF <br />CER - <br />TYPED OR PRINTED n,ludirg the rK?ssibility of tine and imprisonment for knowing rsnlanoe FI <br />OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />nere) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. <br />OCrC. .: ;::1This is n 4,1,art form.