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PERMITTEE NAME/ADDRESS drirfudr Farilitr'a'amr,7..rariun illliffrrenti NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION _ FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />LIT 1 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF <br />LYSIS SAMPLE <br /> <br />TYPE <br /> ANA <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT '/4 /I L <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under Penalty oI I- that this d,Kument and all attachments were <br />Prepared under my dine ui -,r suPa•niciin in accordance with a syslem dc. ignad ( : _ <br />f TELEPHONE DATE <br /> <br />'? •- - In assure that qualified p -unel Priprrh gather and esahuule the infurmati.at <br />submitted. Raid in my inyiir. of the I,rrsnn or prrs.ius whi manage the system. <br />or th.ne persons diredlr r.-•J»m.ildr for gathering the information, the information ! <br /> <br />_-- l -- <br /> <br />-. <br /> submittal is. t., the best it nn knowledge and belief. trio,. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there ar, •ignifie2rd pemdlies fir suhnuuing raise mrormatirm. <br />T <br />AREA <br />TYPED OR PRINTED including the lm-ihility 0 fine and imprisonment for knowing siulation, OFFICER OR AUTHORIZED AGEN NUMBER <br />CO YEAR MO DAY <br />COMMLN15 ANU tAYLANAIIUN Ur ANT <br />1nr, c, cn?r on aaaoa......c..ao ..?. ?r <br />21, PG. 4 FOR REGt1IREMENTS <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used :)0c) t This'is<a 4-part form.