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PERMITTEE NAMEIADDRESS (Include FaeJUv,laatallitraa,w if Differriat NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />I ST I Pit( <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrlirs under penalty of law that this d-ument and all attachments were <br />dir"tiun or w <br />t•rsision in --lance with a % <br />re <br />ared under m <br />stem desi <br />ned TELEPHONE DATE <br /> p <br />p <br />y <br />p <br />i <br />g <br /> to awrre that qualified Personnel proped"% gather amf rsaluate the information <br /> suhmitled. Bascd on my inquir7 if the Prr.,m or pcr%ons who manage the system. - <br /> or those ri-ris directly responsible for gathering the information, the information <br />- - ,_ submilleil is. to the best of mi knowieefge and hrlkr. true. acrurale. and cumpktc. <br />- enalties Gee wbmiltin <br />1 am aware that there arc si <br />nificant <br />false information SIGNATURE OF PRINCIPAL EXECUTIVE <br />` <br />TYPED OR PRINTED g <br />P <br />g <br />. <br />including the possibility of fine amf imprisonment for knowing siotations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.