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w Di%RESS <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 />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION No. FREQUENCY SA <br /> >< EX <br /> - <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F' I <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 TITLE PRINCIPAL D(ECUTIVE OFFICER 1 snit} undue penalty of law that tins daurrtent .md all enachments wen: TELEPHONE DATE <br /> prepared under my direcnnn or supervision in accordance wnh a system deKgzned <br />-- - to assure that qualified pcrxtnnel properly gather and esaluatc the information <br />- -- - _ -r <br /> _ <br />subrt»tt et Rased on my inquiry of the pemin or perscurs who tnanace the system. <br /> or those pervns directly rearomible for gathering the mGutnaunn, the Information - <br /> submitted is- to the hzst idtny knowledge and belief, true, accurate, and eumpletc SIGNATURE OF PRINCIPAL EXECUTIVE <br />I a <br />th <br />t th <br />i <br />b <br />l <br />f <br />k <br />f <br /> <br />TYPED OR PRINTED nt aware <br />a <br />ere are slgmt <br />cant pena <br />nus fur su <br />mitung <br />a <br />e in <br />orntatunt. AREA <br />OFFICER OR AUTHORIZED AGENT <br />indudm <br />the posubdit <br />oliim and im <br />r <br />on <br />ent f <br />n <br />k <br />i <br />l <br />= <br />E <br /> g <br />y <br />p <br />is <br />or <br />now <br />ng vto <br />m <br />a <br />, NUMBE <br />R YEAR MO <br />ons <br />eR <br />COMMENTS AND PLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA Form 3320-1 (Rev. 3,199) Previous editiuns may be used. <br />This is a 4-part form. PAGI <br />MPLE <br />TYPE <br />DAY