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PERMITTEE NAMEIADDRESS (include Pacifity.Vane/Location if lAJfrrent) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />'IrFF PRE, <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 /> <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 /> <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certip under penalty of law that IN, document and :dl amachments were <br />Prepared under nn dirtttion or Mtprr.i.ion in accordatwr with a ssstem designed <br />TELEPHONE <br />DATE <br /> to assure that qualified personnel properi- % Rather and esalratr the information <br /> submitted. Rid on m) inotm ad the Pe-n or persons who manage the system. <br /> or th - persons directl• responsible for gathering the information, the information <br /> submitted is. to the best of mi knowledge and belief. true. accurate, and complete. <br />I am aware that there are si <br />nificant <br />enalties for submittin <br />false inrormation <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />F <br /> g <br />P <br />. <br />g OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the pansibilits of rare and imprisonment for knowing siolations. <br /> <br />NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-Part form.