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PERMITTEE NAME/ADDRESS (Include Farilin Num, t a nm,n if Piff rnu. <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. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <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 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certif' under panalt, nriaw that this document and all attwhmenf, were <br />w TELEPHONE DATE <br /> prepared under ms d <br />eelion or supersision in accordance with a stem designed <br /> Iu assure that qualified pemwmel pr,,wrh gather and n duair the informatinn <br /> submitted. Rased on m% iogai" ur the person or Persons who manage the s'sstem. <br /> or Ili- penotn direcds nsponsihle tow gathering the information. the informmtion <br /> submitted is, to the iw-t or m) km,oladge and belief. true, acell ate. and a-.mpl t,. <br /> <br />1 am aware that there <br />r <br />nifi <br />ltim fur <br />si <br />nt <br />ub <br />itti <br />l <br />i <br />f <br />ti <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED a <br />e <br />ca <br />pena <br />s <br />m <br />se <br />n <br />g <br />ng <br />a <br />orma <br />on. <br />including the posihiliSY of fine and imprisonment for knowing ,iodations. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />D <br />YEAR <br />MO <br />DAY <br />frle/ere IGe d1/ d1idGfflffef15 "ere) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-Part fon-n.