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PERMITTEE NAME/ADDRESS Unrlude Far",11'amel oration if lhffereno 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 FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />OMB No. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF <br />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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I crrtif <br />? wider penalh o(law that this docununt and all attachments wrrr TELEPHONE DATE <br /> prepad under m? direction or suprn Wwi in nccurdancr with a ystrm desiUned <br />re <br /> to as- Ihni qualified pemnin l properly gather and es aluate the information <br /> .submitted. Rased on m% inquiri of the person or perwms wMi maaagr the -tem. <br /> or th- persons directly responsible for gathering the inrormahnn, the Information <br /> uihmilted is, to the best of m± knowledge and belie(. Inte, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that the" we signifKant penalties for submitting false information. <br />owi <br />riol <br />ti <br />nd im <br />riso <br />me <br />t fo <br />k <br />ns <br />h <br />lih <br />f f OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED irer a <br />p <br />n <br />n <br />r <br />n <br />n <br />n <br />' <br />including the Iw si <br />i <br />o <br />ng ODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3M) Previous editions may be used This is a 4-part fomi.