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PERMITTEE NAME/ADDRESS Ilncladt FaciWY Namdlocation if Different <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 />rl-k' :l_. ,IFILi O IIVLIl U <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <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 /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certifs under penalh of law that this document and all attachments were <br />r <br />• <br />rd <br />nd <br />r <br />dir <br />ti <br />i <br />d <br />• <br />i <br />i <br />i <br />h <br />i <br />d TELEPHONE DATE <br /> p <br />a <br />par <br />u <br />e <br />nn <br />ec <br />on or %upc <br />rv <br />on <br />n accor <br />s <br />ance w <br />t <br />a system r <br />vsigne <br /> i, assure that qualirted perxmncl properly gather and rsuluale the information <br /> suhmitled. Based on ms inyuirs of the perwm or per.on., who manage the %tstem. <br /> or (hone persons dined reslamsitde for gathering the information, the information <br /> submitted is, to the lwvt of m7 km-l"Igr and b lien. true, accurate, and complete. <br />1 am xwarr that 111e•re arc sigmr-ut <br />enaltie, for Nlbmilling W- Information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />- - - - ..... - p <br />, <br />including the {ansibiliq of fine and impri-f-wul for knowing siolations. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />AND EXPLANATION OF AN <br />?. "' L <br />(Reterence all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 9 This is a 4-part form.