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PERMITTEE NAME/ADDRESS anew, Focififc \ama7 am r, if Niffrrrmi NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <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 /> <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 s <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cerifry under penalp of law that this doci n ent and all attachments wem <br />direction or u <br />-ision in accordance with a , <br />r <br />arc<I under m <br />%,t"t deci <br />nnl TELEPHONE DATE <br /> p <br />p <br />? <br />p <br />g <br />' <br /> to assure that qualified personnel properi' gather and e,:duate the information <br /> submitted. Based on m) inquiry of the person or persons who manage the %,,trm. , <br /> or those persons dir-tl- % resiwm,ibh• for gathering the information, the information <br /> submitted is. to the best of ms knowledge and belief. true, accurate, and complete. <br />fo <br />b <br />fo <br />aton <br />1 <br />m aware th <br />t th <br />r <br />t <br />e <br />lti <br />s <br />itti <br />false i <br />i <br />ifi <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />' <br /> a <br />a <br />em a <br />e s <br />gn <br />can <br />p <br />na <br />r, <br />m <br />ng <br />n <br />rm <br />. <br />r <br />u OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED inelmling the pm,ibilit% or fine and imprianmeni for king sioiatiuns. NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.