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PERMITTEE NAME/ADDRESS tinrlude Farditr \ume;b-it n if Uiffercnn 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 YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />SH 05CH"UNNMU TRID/HUBBARD C,F <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i :.. <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I -e r> under pe-11% 4 In% that this dow-ument and all attachmenti were <br />ared under m <br />di <br />ection or w <br />i <br />r <br />eri Mo <br />cco <br />d <br />nc <br />with <br />s <br />st <br />d <br />si <br />d TELEPHONE DATE <br /> p <br />ep <br />? <br />r <br />p <br />n <br />n a <br />r <br />a <br />e <br />a <br />y <br />em <br />e <br />gne <br /> In aasare that qualiritd personnel pn Verl} gather and esahcttr the inGtrmat{on <br /> suhndllM. Ita-d on ra,% inquirry or the pe-n ur pe-, ..hu manage the, <br />ystem. <br /> or those penon. directly rmponsihlr for gathering the information, the information <br /> suhmitud is• t.. the M•st or nit AnowlydEv and Iw lief• tri aratrair, and complete. <br />I oot ..art that thrtr qtr .ignifiram prnoltic. f- .u1 (tin <br />, hdnrm:di„o <br />IA. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> g <br />. OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED ut<htdmn it,, pw.ibdVn d Ilnr ,md unpn-mment bw hn-in,-, u l uinns. NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev, 3199) Previous editions may De used. This is a 4-part form.