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PERMITTEENAMEiADDRESSlb,..rudeF: i(trv.blame,bxaliuarfU,Jfan•nu <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 /> <br />QUALITY OR CON <br />E <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 a <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ..... q :, .} .. <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 ccri,N under pcnalry of law that this do untcnt and all amidhntents weir TELEPHONE DATE <br /> prcpared under my direction or supervision to accordance with a ? tem designed <br /> a assure that qualified personnel properly gather and evaluate the mformation rT <br /> submitted Based on my Inquiry of the person or persons who manage the .ystcm. <br />• <br />" ?`'i <br />'? <br />- <br /> <br /> <br />L" or those penoms dircak rcspunsrble for pthenng the information. the inforrnannn <br />submitted is <br />to the fkst of m, knowled <br />lch. <br />e and belief <br />tie <br />accurate <br />and com ° <br />- <br />i <br />' <br />-) <br />:1 - -? ,"" / ' '•'? <br />` - <br />- i <br />r i . <br />g <br />. <br />p <br />. <br />. SIGNATURE OF <br />PRINCIPAL EXECUTIVE c- <br />7 <br /> 1 am aware that there arc stendu•ant txnalucs for submnnne false information. ". <br />TYCO UH VKIN ItU I m, [N .•. n: hit 4 hn?.:r„ bn knowing vwlunons <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />CENTRATION Np. FREDUENCY SAMPLE <br />EX OF TYPE <br />NUMBER YEAR MO DAY <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. `(? 1 i ?• '. This is B 4-part form. PAGE OF