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PERMITTEE NAME/ADDRESS ilnrlude Farifin %anwbwaiwn i? UtJlrrrnr <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- 2040-0004 <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 1 - <br /> REQUIREMENT <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 /> 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 1 arnt! under pen:du of Ian that [hi. d-ument and all attachment Mere <br /> <br />i <br />i <br />d <br />ith <br />t <br />d <br />di <br />c <br />i <br />i <br />d <br />i <br />d <br />TELEPHONE <br />DATE <br /> on or wpera <br />n accor <br />ance w <br />pn"parrd un <br />er m} <br />re <br />t <br />s <br />on <br />a sys <br />em <br />t <br />>:nr <br /> n -tire that quahRNl personnel properla gather and raaluatr the information <br />I <br /> submhted. Flased on my inquirs of the Far-nor fw"rsons who manage the sa stem. <br /> wr th- pa"- diraet}y respamsible for gathering the information, the information <br /> submitted is, to the Iw•st of my kra-l dge and helief, tna•, accurate, and coanpkh•" <br />ir <br />t <br />lti <br />b <br />l <br />I <br />h <br />h <br />i <br />- <br />f <br />it <br />i <br />f <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED ere are s <br />ormat <br />am aware t <br />at t <br />gn <br />w <br />ua <br />pena <br />es <br />or su <br />m <br />t <br />ng <br />a <br />se <br />n <br />on. <br />including the pnssibilit of fine and imprionmrnt for knowing aiolatimts OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev- 3199) Previous editions may be used. This is a4 -pan form.