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PERMRTEE NAMEIADDRESS lincludr Facility Aame/Gxation if ihfferenti <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />( a( <br />F <br />Form Approved. <br />OMB No 2040-OD04 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. OF FREQUENCY SAMPLE <br /> EX 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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <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 certif.s under prnahh of law that this dtwument and all attachment% were <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> a )stem <br />prepared under ms direction or eapersisimt in accordance wit <br />es <br />gne <br /> to assurr that yuali6ad Pe-ond prowd-% gather anti esaluale (he information <br /> ?abmilttd. liasad on my inquire or the peruan or persons who manage the system, <br /> or those persons dirtdly r yponsiblr for gathering the information. the information <br /> submitted is- to the Ixst of m's knnwledvr and Iselief. true, a Yvralr. and ctanploele. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED 1 am aware that therr are signirwant penalties for %uhmitting raise information <br />including the pmsibility (if fine and imprisonment for krm%ing sitolation, OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.