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PERMITTEE NAME/ADDRESS (include Facility lann,l-al oe it hiff rrrrt- <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-OD04 <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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 remit, under Penulq wr law that this document and all attachments were <br />d <br />h <br />- <br />d <br />i <br />d TELEPHONE DATE <br /> prepared under m? direction or %ul- sion in accor <br />ance wit <br />a si <br />stem <br />es <br />gne <br /> to asatre that ytwlified perwmnel properly gather and eealuale the inrormation <br /> submitted. Basal im ms inquiry of the lwr or persons who manage the sestcm. <br />` <br /> or those persons directll respm4ble fur gathering the information. the information <br /> knowledge and heiirr <br />true <br />"curate <br />and complete. <br />submiuad is <br />to the heel of in <br /> , <br />) <br />. <br />. <br />. <br />f <br />h <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> on. <br />1 am aware that there are significam penalties <br />or w <br />mitting rake informat AREA <br />TYPED OR PRINTED including The "%ihility of nor and impriwnment for knowing "Autions. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO 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 a 4-Part (OCIII.