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PERMITTEE NAME/ADDRESS ducludr la, da( N n, l •n a;r n i! Ihprr,nn <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMA) <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 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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtiQ under prnaltr of law that this document and all : tlachmenL• were <br /> <br />Prepare) under its direction or vttpeniiun in accordance with a gstem designed <br />TELEPHONE <br />DATE <br /> to assure that qualified prrnunnel properly gather and esalnate the information <br /> submitted. Rased on my inquiry of die person or person, who manage the sestem, <br /> or Ihosue pe-- direcfly resprmsihle for gathering the information. the information <br /> submitted is, to the hest or m% knowledge and Mier. true, amurutc, and compkle. SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> I um aware that there are signirtcant penaltle+ for submitting false information. AREA <br /> risonment for knowing siolutions. <br />ssibilih of rim and im <br />i <br />ludi <br />the OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED p <br />nc <br />ng <br />ri DE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all affacnmenfs nere) <br />EPA Form 33320-1 (Rev. M9) Previous editions may be used. This 1S a 4-part form.