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PERMITTEE NAME/ADDRESS (Include F"ffity Aame/loraeon if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPOES) <br />DISCHARGE MONITORING REPORT (D R) <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 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rerlifry under pemdu of hre that lhi%d-ument and all attachment% %em <br />ared under m <br />direction or su <br />wrvi%ion in accordance with a s <br />stem dei <br />ned <br />re TELEPHONE DATE <br /> p <br />y <br />g <br />p <br />p <br />i <br /> t,, assure that qualified perw,nnel pruperli gather and csaluate the information <br /> submitted. Baud tut m) inquiry of the person or persons who manage the system. <br /> or Ih- persons dirmill respnWhit for gathering the informaton. the information <br /> suhmillrf is, to flit ha.1 of my knowledge and W- id. true. accurate. and complete. <br />m <br />ware th <br />st <br />nirtc <br />nt <br />nalties for submittin <br />false information <br />I <br />t the SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED pe <br />g <br />, <br />a <br />a <br />a <br />re arc <br />g <br />a <br />including the r-sibilki of fine and imprisonment for knmviny, violation.. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />)EMIT A REG <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part Form.