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PERMITTEE NAME/ADDRESS ibvludr l<vrifi(r lumrrl ,ration if Itilf rrnt, <br />NAME <br />ADDRESS <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 />F"! 1 <br />( J <br />F <br />III <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 i :. <br /> REQUIREMENT a ._ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT `- <br /> REQUIREMENT :JvH )ice. i - <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify undt•r pendty of law that thiv doeun-1 and all attachmenh were <br />tk <br />i <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> prepared under my d <br />rection or vurwr <br />itm in accor <br />ance w <br />t <br />a system <br />es <br />gne <br /> to avvum that yualined per nnel properly gather and evMunic the information <br />.uhmitted. Bayed on my inquire of the perwm or pervtn who manage the syslrm, <br />- <br /> or tho- per ores directly recpm+ihle for gathering the information, the information - ' <br /> submitted i., to the hevt ,d my knowledge and belief, true, accurate, and complete. <br />b <br />h <br />n <br />l <br />l <br />F <br />i <br />i <br />f <br />k <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that t <br />ere are signi <br />canl penu <br />t <br />n <br />or w <br />m <br />tt <br />ng <br />a <br />e <br />n <br />ormat <br />on. <br />including the lewibilitc of fine and imprisonment for knowing shdatbms' 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 />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is S 4-part form.