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PERMITTEE NAME/ADDRESS (Include Facility Namellocation if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />1 1. <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 /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />E <br /> EX ANALYSIS TYP <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 /> <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 .rrlify under penalty of Iaw that this document and all attachment. werr <br />m <br />nl <br />nd <br />, di <br />ti <br />i <br />i <br />i <br />h TELEPHONE DATE <br /> p <br />par <br />u <br />er m <br />on or wper? <br />rtr <br />. <br />on <br />n --rdance wit <br />a ..Hem desiRnrd <br /> bi -ure that yualiried 1-onmi proprrlt rather and -. Iuule the infurtrudieat <br /> enbmiued. Reed on mr inquire of the p•rum or pe-R, who manugr the .'stem. <br /> or those p•r,on• direeth rt patcible for gathering the infornwtion. the information <br /> .ubmltbd k. to the lard of m.? knu%l dgr and belief, true, accurate. and cranplete. <br /> <br />I am aware that them are ci <br />nifkvnl <br />enalties for uhnniffn <br />falw inform <br />tion SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />p <br />g <br />a <br />. <br />kwhrdiog the pndbilih or fine and imprhunmrnt for knowing violations <br />I <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />k.Ulnmr-n I J AfgU cnrt_rafvrt I IUfv Ur mri T <br />rererence, au arracnmenrs nerej <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.