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PERMITTEE NAMEIADDRESS (include Facility Namelb,cation if Differrnh NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />I FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY FROM TO YEAR MO DAY <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 /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> 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 />NAMErfITLE PRINCIPAL EXECUTIVE OFFICER I ,erhR uudcr I-flt, ,f L- that this d-ument and all attachments oere <br />i <br />i <br />i <br />d <br />ith <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> on ..r .uprrs hiun <br />n -or <br />pn pared nndcr m+ d <br />nrt <br />ancc p <br />a ,s <br />em <br />rs <br />gne <br /> or aoum that qualiried personnel properl% Rather and etaluate the information <br />mhmiwA, Based nn m7 inquiry or the It"rson or persons wh.r manage the system, <br /> or thous person% dimcll' % rrspmsihir for gathering the information, the inrurmaliun <br /> submitted is, to the best urmi knowledge and Wier. troe. accurate, and complete. <br />hi <br />h <br />l <br />i <br />i <br />h <br />i <br />ir <br />I <br />i <br />i <br />r <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED tcmn I-a <br />- Bo <br />m <br />.e <br />n <br />am uw am that t <br />ere am s <br />gn <br />- <br />tl <br />ng <br />a <br />.nnat <br />nn, <br />including the p-ibilits of low and uupb nunrot bar knowing .iulati.-. <br />OFFICER OR AUTHORIZED AGENT AREA <br />O NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />1 EPA Form 33-,U 1 Pes 3"99 P•;; c,s •_d t rs I'his is a 4-part form.