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PERMITTEE NAME/ADDRESS (include Faeifin Namell.ram.rt it Differml, 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 />)IJTT <br />NOTE: Read Instructions before completing this form. <br />METER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO, <br />FRED 1- <br />OF <br />SAMPLE <br />PARA EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / ?. <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE I P, <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ? <br /> MEASUREMENT <br /> <br /> PERMIT , <br /> <br /> REQUIREMENT <br /> SAMPLE ` I t f P-1 F. <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br />'~ , 1 I <br /> <br /> PERMIT E r <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rertif) under pen:dl) of Lre thin this d-uneut and all attachments ttere TELEPHONE <br />ned C <br />with <br />y <br />te <br />desi <br />d DATE <br />... - _ _ <br />s <br />m <br />g <br />ance <br />a s <br />prepared under m% dim n- ro uwrsi%ion in accor <br />to assure that qualified Its n.-nnei properh gather and esahlule the information - <br />son ttho <br />n <br />e the s <br />stem <br />--- '?' -?- <br />h <br />g <br />y <br />, <br />e Perim or Per <br />ma <br />submitted. Raid on my uupur ? or t <br />s or those pecans directt) n sl.msiblr for gathering the information, the information <br />` - submitted is. to the bea,d tit, km-[edge and belief. true. accurate. and rnmpkte. SIGNATURE OF PRINCIPAL EXECUTIVE <br />J <br />C e I um uttarr that there an- •i"nifioum penalties for submitting false information. <br />R OR AUTHORIZED AGENT <br />O <br />I AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the pug ibilth „f rh,r and imprisonment for knotting sbdatituu. FF <br />CE D <br />COMMENTS AND EXPLANATION OF ANY VIULAIIVNV Iriererence du <br />EPA Form 3320.1 (Rev. 3/59) Previous editions may be used <br />JR - <br />r• 9 <br />4, FOR REv'itt'sfi)'P'11=N <br />I hi. i. a -' i?!ir: (i i_;I-,