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PERMITTEE NAME/ADDRESS ditclude Faciliq.fame/Location if i ifffrrno <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />F <br />C t- <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I rerttf) under prnaln wrI- that this dravtnelll and all attachment., were <br />TELEPHONE <br />DATE <br /> prepared under m) dimtmn wr super isi(m in aerurdance with a s)slem designed <br /> I,, assure that qualified pm-el properl, gather and -alualr the inrnrmathm <br /> submiurd. Based (on m) inquiry of the pennn or prone who manage the c)stem, <br /> wr lh- pe-, directly res xmsibir fur gathering the inrormaliwn, the infonnalinn <br /> suhmitled is. to the he, 14 m% kmrwledge and Wier. true, w -urale, and cumpletr. <br /> I am aware that Iher are signirwant <br />enalli <br />for sub <br />itti <br />false inG <br />li SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED <br /> <br />ern warn rune • p <br />n <br />m <br />ng <br />rrma <br />nn. <br />imlading the 1-ibilit, wt. fine and impriwnment for knowing siulations. <br />_ .. .. OFFICER OR AUTHORIZED AGENT <br />I AREA NUMBER <br />CODE YEAR MO DAY <br /> <br />RP1 <br />A7 <br /> <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This i5 a 4-part font.