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PERMITTEE NAME/ADDRESS Include FaeiHj.r.%jj n,j,omiun it Uilfuror <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 />FROM YEAR MO [_2A9 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• FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <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/nTLE PRINCIPAL EXECUTIVE OFFICER I cerlih under Iw-11% „flaw that thi%d-ument and ,m attachmenh were <br />d <br />d "- TELEPHONE DATE <br /> prepare <br />un <br />er m din•cti„n or mir- ,tun in ucc„rdancr with a system deigned <br />lw ? `??, 1 _ •.?..? __ \ i ,?? to n.arre that qualified p.•rvmnel pr„perh ¢alher and et alvuta• the infarmalian _ ?_ _ __ <br /> suhmilitd. Haled on m mquin of the person or pvrwns wh„ manage the -stem, - - <br /> or thou pers„n, din,tl r,j on>rbtr for gulharing thr inrarmalion. the information <br />J - ? l ...? suhmiWd is. to the 1 1 .1 rm knowledge and behel, true, accurate, and complete. <br /> I am ..are that tfu•re an i <br />ir <br />ltn <br />f <br />r vthmiltin <br />fad <br />i <br />ti <br />f SIGNATURE OF PRINCIPAL EXECUTIVE / <br />TYPED OR PRINTED gn <br />want pena <br />u <br />g <br />n <br />orma <br />on. <br />, <br />, <br />iniuding the Iwnsibilit. „r fine and impri-nment r„r kn„wing.iolati„n, OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />here) <br />EPA Form 3320.1 (Rev 3199) Previous editions may be used. ji This is a 4-part form.