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PERMITTEE NAME/ADDRESS ilncfade P'ac•ilin ?c n,• 1 oration if Pitlerren NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <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 SAMPLE <br /> <br />I>< <br />EX OF <br />TYPE <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 /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certif. under penalls of law that this diamnent and all utlachmenh were <br />e <br />u <br />d und <br />r - dir <br />cli <br />r <br />%ki <br />ith <br />i <br />d <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> pr <br />p <br />rr <br />e <br />oo o <br />supcr <br />mr <br />e <br />n a-or <br />ance w <br />a sys <br />em <br />tr <br />gna <br /> 1.. assure that tiwliried pen.mnei prnperl'w Mather and esahade the information <br /> gthmittad. Rased .m ms inquiry of the tkrson or Pennns who manage the .'stem. <br /> or th- tw•n.ms dimity resp-ihle for gathering the inrormation, the information <br /> sohnntlyd is. 1.. the liest of my Anowlydga• and belief, true. atvu"Ie, and complete. <br /> I am aware that there art significant penalties for submitting false information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED , <br />including the possibilit of floe and imprisonment for Anmsing,wlations. OFFICER OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />COE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />Ur ANY VIULAIIUNS (xe?erence an attacnments nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-part fOf1Tt.