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Form Approved. <br />PERMITTEE NAME/ADDRESS fwfud, Fuifitr .1'ame/lairnrion iJ Di(frrrnh NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY <br />LOCATION <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />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 i <br /> REQUIREMENT 1'-= <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certifs under penalt% of law that this d-ument and all attuchtnrn % were <br />r with a crdr <br />si <br />d und <br />r n <br />di <br />cti <br />n <br />r su <br />l <br />n- <br />n in aec <br />da <br />d <br />ed TELEPHONE DATE <br /> prepare <br />e <br />n <br />re <br />o <br />o <br />l <br />o <br />or <br />nc <br />ni <br />e <br />gn <br />e <br /> to as+urr that gwdifird prm,nnel proprris gather and --luau the inr0Mk1irm <br /> cubmitled. Based rm m? inquiry of the person or prrwns who manage the yslem, <br /> or those I-its dire-c911 rrspmcible for gathering the information. the information <br /> submitted is. to the best of ms knowledge and belief. true, accurule, and complete. <br />b <br />I <br />h <br />h <br />i <br />i <br />k- <br />l <br />i <br />f <br />i <br />i <br />f <br />l <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED or su <br />am aware t <br />at t <br />ere urr s <br />gn <br />f <br />nnt pena <br />t <br />es <br />m <br />tt <br />ng <br />a <br />se <br />n <br />orma <br />on. <br />including the lunsibility of fine and intprnonmenl for knowing siulation. 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 a 4-part form.