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PERMIT7EE NAMElADDRESS ,Include Pacilirr samelhication if htffrrrnl! NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />?R GSC Vi! IJNNMD <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 /> 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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eertH> under penalty of law that this document and all attachments were <br />d u <br />d <br />dir <br />ti <br />vi <br />with <br />i <br />i <br />d <br />t <br />d <br />d TELEPHONE DATE <br /> prepare <br />n <br />er mi <br />on or super <br />s <br />on <br />n accor <br />ance <br />ec <br />a vs <br />eni <br />esigne <br /> to assure that yuuliried persomid properll gather and esaluate the information <br /> submitted. Rased on me imluirs of the person or persons who manage the s-irm, <br /> or thorn persons directh reti nsible for gathering the information, the information <br /> submitted is <br />to the best of mi knowledge and belief <br />true <br />accurate <br />and com <br />lete <br /> , <br />, <br />, <br />, <br />p <br />. <br />I am aware that there are signirwant <br />enalticss for submitting false information <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED p <br />. <br />including the p-didity of fine and imprisonmrm for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used <br />(Reference all attachments here) <br />This is a 4-part form.