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PERMITTEE NAME)ADDRESS (Include PacilitiName .,ration tj bift r,ru, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 />(51 <br />F <br />4N I SOfV R VI <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. 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 /> <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I -rtifs under p•nah' % of law that this d,xument and all attachments were <br />direction or su <br />e%kion in accordaner with a s"*Nem desi <br />ned <br />e <br />ed under m TELEPHONE DATE <br /> p <br />g <br />Pr <br />par <br />% <br /> to as ure Ihal yuahfied Personnel properly gather and es aluate the information <br /> submitted. It-led ins 9n1 inyuin of the person or persons who manage the system. <br /> or lh- Persons dirmtl re prnsihle for gathrruw the information, the in(urnwtiun <br /> submitted is, to the hest of m,s knowledge and belief. true, accurate, and complete. <br />nific <br />nt <br />enalties for submittin <br />fakir informati n <br />I <br />.wa <br />th <br />t the <br />re si SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED P <br />g <br />. <br />am <br />rt <br />a <br />m a <br />g <br />a <br />including the p ssihdity or fine and imprisonment for knuwing siolations. 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. 3199) Previous editions may be used. This is a 4-part form.