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PERMITTEE NAME/ADDRESS r/ntdurk /'a ilih•.ti uar'Lururinn tJpi/T n nO <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 />)rrn Approved. <br />MB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY S <br /> EX OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT } <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccruR undet penalty of law that this d.Kuntcnt and all an:?vhments were <br />prepared under my dirwiLln o r supervisi,m to accordance with a sV tern designed TELEPHONE DATE <br />_ <br />h <br />l <br />d <br />l <br />5 <br />* <br />t„:::sure t <br />at qua <br />ifie <br />personnel proper <br />y gather and evaluate the information <br />167 <br />b <br />ed <br />su <br />mitt <br />Ba wl on my inquiry of the person or Ixnon, who manage the :ivctem, <br />or thu>- pcrsuns directly responsible for gathenns the information, the mfumtanOn <br />L7- <br />, L <br />b <br />d <br />. <br />su <br />mitte <br />is. to the hest of my knowledge and belief. true. accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />'C <br />1 am aware that there an significant prnalucs for submntme mise ndixmafion. <br />v.. . I ,,, _ uqn ..vunrm n,....... wing vunnuuns I -- ' -• - -' - •- <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />AMPLE <br />TYPE <br />YEAR MO DAY <br />EPA Form 3320-1 (Rev. 3:199) Previous editions may be used. This is a 4-part form. PAGE OF