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PERMITTEE NAMEiADDRESS (In, lurk Fmvhn ,Yunre bNrnrun i% OrIlemni) <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 />X <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> ANAL <br />IS TYPE <br /> YS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />:- t REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br />i MEASUREMENT <br /> PERMIT <br />t = 7 L ,• iT? REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />MEMTLE PRINCIPAL EXECUTIVE OFFICER <br />N I ccrtiffi under Ixnelnr of taw that this document and all :ntachrnentc were TELEPHONE DATE <br />A direction or superersron in accurdanre with a system designed <br />d under m <br />t <br />ar <br />Mm non <br />diehard A p <br />ep <br />c <br />% <br />to assure that qualified per.onnel proper' gatherand e%aluatc the mhxrnatmn <br />du s <br />stem <br />n <br />h <br />i <br />i <br />f <br />h <br />. y <br />e per.,on or persons w <br />o ma <br />age <br />. <br />re o <br />nqu <br />t <br />suhmntcd. Based on my <br />the mGrmtation <br />the information <br />) <br />hle t <br />r <br />atherin <br />d <br />tl <br />C-'? <br />Vice President , <br />irec <br />o <br />g <br />g <br />or thosepersons <br />y resp <br />na <br />d <br /> complete <br />suhmnted is. to the hest of my I:nowle(Ige and hehef, true, accurate. an SIGNATURE OF PRINCIPAL EXECUTIVE <br /> false miunnaunn. <br />aware that there me ,rgniticant penalties fur ,ubrnlttmg <br />I am AUTHORIZED AGENT <br />OFFICER OR AREA <br />AY <br /> w <br />l <br />ti <br />n <br />t f <br />k <br />i <br />i <br />d <br />n CODE NUMBER YEAR MO D <br />TYPED OR PRINTED sr,nmen <br />g <br />a <br />o <br />s. <br />m <br />unp <br />or <br />nu <br />u <br />nclung the pu>sihthnof t <br />ne an <br />di <br />OOMMENTS AND EXPLANATION of ANY VIULAI IUNb <br />ao asacnmenrs nnrr) <br />EPA Form 3320-1 (Rev. 3,199) Previous editions may be used. _ This is a 4-part FOnn.