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PERMITTEENAMEr'ADDRESSilneludeFaciRrs,Name.L m,, rlDifferenu <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATIONr <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 />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SA <br />OF <br /> EX <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certth under penalp ,n law than this drwu lent and all auachments were <br />d <br />d <br />d TELEPHONE DATE <br /> ance K nh a system designe <br />prepared un <br />er my direiaom or supanision in accor <br /><-- <br />?- - t„ iisure that quahtied personnel properly gather and eyahuatc the information <br />. submitted Bused on my inquiry of the person or persons who manage the system. <br /> or those persons directly responsible for gathering the information. the mfomation - <br />_ submitted ts. to the hest of my knowledge and belief, true. accurate, and cornplete SIGNATURE OF PRINCIPAL EXECUTIVE - - ?' <br /> am aware that there are a;,mficam penalties for submitting false intortnauon. <br />MPLE <br />TYPE <br /> <br />TYPED OR PRINTED nau,hnc the hilnv ; f f:c, en., un n.onrnent b r nmtin ytolanons I 0-Un vn AU r ORIZED AGEN I I CODE NUMBER YEAR MO I DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous eddions may De used. "T[l1S 1S a 4-part folnn. PAGE