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PERMITTEE NAMEIADDRESS,D:, l,u]e Focilin Name:Zxarion if Ul//i,n•nh <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 70 <br />PARAMETER QUANTITY OR LOADING <br />CONCENTRATION NO. FREQUENCY SA <br />QUALITY OR CON <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br />rt. 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 />T REQUIREMENT 3t.. <br /> SAMPLE <br />C MEASUREMENT <br /> PERMIT -, <br />c REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/nTLE PRINCIPAL EXECUTIVE OFFICER 1certify under rvenaltr of law thus this document and Al mtachntrnts were TELEPHONE DATE <br /> prepared under my direction or supervision in accordance with a sv%w"i,jc igncd <br />G.. - - :,, ? urc that qualified perWmnel properly gather and evaluate the oformanon _ /-- _ <br /> suhmnted. Bascd on my mgmry of the person or persons who manage the systcrn. <br />` <br /> at those penons dnoZtly resp„nsibic for gathering the intonnatton. the tnfomtan„n .Z? <br />lam! L? ?•x <br /> whmfnr,i is to thr hra of r,,, l nrn. 1"1., ,0:1 1-1-f o, .. curat • mJ 'um 1•u <br />MPLE <br />P ` - SIGNATURE OF PRINCIPAL EXECUTIVE <br />false lationN on' OFFICER OR AUTHORIZED AGENT AREA <br />is vu!latwns. NIIMRFR VF, <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br />EX OF TYPE <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-Part form.