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PERMITTEE NAME/ADDRESS dwhak• Fwdin.tiame'[in•ation if Different) <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 />NOTE: Read Instructions before"completing this form. <br /> FREQUENCY S <br />NO <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION I . <br />OF <br /> EX <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c . <br /> REQUIREMENT <br /> SAMPLE <br />• i 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 EXECUTIVE OFFICER I certify under penaln (it law that mu d-ument and all attachments wen TELEPHONE DATE <br /> prepared under my dirl'lUiln or superskion in accordance with a system designed <br /> <br />I to assure that qualified personnel properly gather and e•.aluate the information <br />j! Lil <br />.' submitted. Based on my inquiry of the persm or persons who manage the system, <br />or those persons mncdy responsible for cathenng the mfirnnation. the information <br />--' - submitted is, to the best of my knotslknlee and behef, true. accurate. and complete SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am uuarc that then arc siEmiliranf pcnaities fnr>vbmiumg false informaui,n. <br />i <br />l OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />TYPED OR PRINTED anoro <br />o <br />including the possihiltty of fine and imprisonment for kii-ing v CODE <br />COMMENTS AND E LANATION OF ANY VIOLATIONS (Reference all attachments here) <br />AMPLE <br />TYPE <br />EPA Form 3320-1 (Rev. 1%) Previous editions may be used. This is a 4-part form PAGE OF