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PERMITTEE NAMEIADDRESS ilnclude Facility .Vantetlarathm 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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 c <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 cerlif% under penal" of law that this document and all attachments were <br />i <br />d <br />ith <br />i <br />i <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> un <br />n accor <br />ance w <br />es <br />preparrd under too, direction or supen <br />s <br />a sys <br />em <br />gne <br /> to assure that qualified personnel properh gather and csuluan• the information <br /> submitted. Rasrd on nrv inquire of the lwnon ar lwncros who manage the sj stem. <br />-" <br /> or those lwrsons directl> reawmsihle for gathering the information. the information <br /> suhmitted is, to the I-t of ni% knowledge and belief. true. accurate, and complete- <br />h <br />l <br />i <br />f <br />it <br />f <br />f <br />l <br />i <br />f <br />ti <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED or su <br />on. <br />I am aware that there are significant lwnu <br />t <br />m <br />t <br />ng <br />a <br />se <br />n <br />orma <br />e. <br />including the possihilil? of font, and imprisonment for knowing cirdations. OFFICER OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.