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PERMITTEENAME;'ADDRESS,bntr,,4 F?ilrn•,4ume'L+rurro.rr/D1(7i•rnn <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 />PARAMETER QUANTITY OR LOADING <br />CONCENTRATION NO. FREQUENCY SA <br />QUALITY OR CON <br /> <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 />NAMElTiTL.E PRINCIPAL EXECUTIVE OFFICER I ccn- under penalty , i law that this dnCnmettl and all auachlnents were TELEPHONE DATE <br /> prepercd under my direction or supen ulon in accordance with a system designed <br /> <br />assure that qualified personnel properly gather and evaluate the intormnnon _ <br />to <br />/ <br />?lG l i - <br />? submitted RasCi nn my inquire of the I>LCwn sir perums who puma-c the s.-sicm. f - --' _ - - <br />. <br />- <br />- or thtsc persons dlr-cok responsible for gathering the information. the mfomtaiwn ! _ <br />" <br />r submitted is it) the best of in% knowledge and behd. n'uc. aCCUram. and complete SIGNATURE OF PRINCIPAL EXECUTIVE <br />MPLE <br />- <br />TYPED OR PRINTED I ut.ludm the po-h;lu} or tine and imprisonment 1•-r knossmg vwhuinn•. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />AMP <br />HORIZED AGENT AREA NUMB YEAR Mb DAY <br />CODE <br />Form Appr <br />OMB No. 2 <br />NOTE: Read Instructions before completing this form. <br />EX OF TYPE <br />EPA Form 3320"1 (Rev. 3,99) Previous editions may be used.