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P E R M I TTE E NAM EIADDR ESS t btrlud• Fuc iNn• .4'nmo l.uvulon i/Di/fe rl 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 QUALITY OR CON <br />CONCENTRATION <br />NO. FREQUENCY SAM <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 s s <br /> REQUIREMENT .l,?rti7 t"1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certtl, tmder penalty of law tlu,l Iht, d+auntcnt and ell attachment, were <br />d TELEPHONE DATE <br /> prep.ve <br />undet my dtrcctir,n or sn(wr ikion in accordance with a %slem deigned <br />1. n, assure that qualified personnel properly gather and esaluatc the in(ntmation <br /> subourted. Based on my inquu) of the person or person, w hc+ manage Ibe ,y,[cm. <br />" <br />- or those persons dlrc fly reryineble tar gathering the mformution. the mkumation •= ' =' - <br /> <br />1 <br />suhnntled is. I., the test of my 6.n sledge and tthct. Intc. aecurato..indn+mp1m, _ <br />... <br />? l . _ <br />• <br />( <br /> <br />f:,l,c mh-rn it'•r <br />1 am aware that there arc igmitcant <br />enaltie, rot submittin SIGNATURE OF PRINCIPAL EXECUTIVE , <br />` y <br />- <br />TYPED OR PRINTED . <br />p <br />g <br />including the poesibihty of tine :utd imprnonntrnt for km-mg, udri.,i" OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO <br /> PLE <br />CODE <br />L,UNIMr-N 10 AIM W r-Al-LMIVN I IWN Ur Mill T 111V WI IVI7J(r1t:1VrC/1Lt! all 0110IIIIICIIIb I IVIVI <br />-R REC I <br />C <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br /> <br /> EX OF TYPE <br />DAY <br />I <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form. PAGE