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PERMfTTEE NAME/ADDRESS Ilncludr Iarda \am, l.,, atu,r, ;7 hrJ/nrnt 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 FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />OMB No. 2040-0004 <br />( <br />F - <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 /> <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 /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif% under penalty of law that Ihi, docurnew and all attachments were <br />pmpand under rn% direction or upon kion in accordance with a -tern dr,ignrd TELEPHONE DATE <br /> lu assure that qualified personnel property gather and eraluatr thc• infurnrution <br /> submitted. Rased an m% inquiry of the person or perwm< who manage thr system <br /> or those "on, dire th ropmnible for gathering the information, the information <br /> ,uhmiited is, to the NM of my kn uoledge and lrrlier, true. accurate, and complete. <br />I am aware that their are si <br />nificant <br />r•naltie, for,ubmiltin <br />false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />p <br />g <br />. <br />including the peessihilit? of nine and tmpro,mmenl fur knowing violation,. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-Part form.