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PERMITTEE NAME/ADDRESS flncludr Facilitf A'ameYl ocalion if Differrntl <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 />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-00()4 <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 />f <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE 1 i <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 />; <br /> MEASUREMENT i `- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certifi under penail% of law that thi%thwument and all attachments wrre <br />d <br />with <br />d <br />d <br />d <br />-W <br />i <br />t <br />d <br />i <br />d i TELEPHONE DATE <br /> irrstiun - supen <br />on <br />a sys <br />em <br />gne <br />prepare <br />un <br />er nn <br />n accor <br />ance <br />es <br /> <br />-"' <br />- to aaure that yuatiried personnel pmprrh gather and esutuatt, the information <br />- - <br />- suhmitted. Rased in m) inquire A the porson or person. who nutrtage the system. <br /> or those person% dimctl. -r. ,nsihic for gathering the information. the information - - ' <br />r sabmilted is. b, the hest d np knowledge and belief, true, accurate, and complete. <br />if <br />b <br />i <br />i <br />ti <br />I <br />h <br />h <br />f <br />i <br />f <br />ti <br />r <br />k <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> orma <br />on. <br />em aadre t <br />at T <br />em an sign <br />want Ixna <br />t <br />rs <br />or u <br />m <br />t <br />ng <br />a <br />e <br />n OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the p-ibilily .d fin, and imprisonment Ln knowing cioLdions. DE NUMBER YEAR MO 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.