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PERMITTEE NAME/ADDRESS doicludr I atihn \amrl. rah wn if Differeml NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION 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, FREOUENCY <br />OF SAMPLE <br /> <br />EX <br />NALYSIS TYPE <br /> A <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 /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty wf luw that thic document rtd all ullwbmenls wort TELEPHONE DATE <br /> prepared under mi direstlon or wprrsision in accaudance with a ,stem designed <br /> to -re that ttualiflod persomnd ra-perh gather and evaluate the information <br /> suhmitled. Rased on ny inyutn of the prrson or prr-- who manage the system. <br /> % responsible for gathering the information. the information <br />or those penons dirtctl <br /> . <br />whmitted is, to the tart of my knowledge and I"k•f. true, accurate. and cornplrle. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am .wore that there are signirw'ant penalties for whmitting false information, AREA <br /> swlationv <br />isonment for knowin <br />th <br />ihilin <br />f r <br />d i <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />e poss <br />o <br />ent an <br />mpr <br />g <br />nc <br />u <br />ng O <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,%) Previous editions may be used. This is d 4-part form.