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PERMITTEE NAME/ADDRESS (include FarUO.Namell r.canwi ()'l)gfrn•nr, <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 />FROM YEAR MO DAY TO YEAR MO DAY <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. <br /> <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 FMS%c <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eertin under penalt d law Ihat this dKUment acrd all aturchntrnU were <br />ce with a - <br />ti <br />r <br />nisi <br />i <br />-c <br />rda <br />cm d <br />i <br />ned <br />d <br />d <br />di TELEPHONE DATE <br /> prepare <br />er m? <br />rec <br />on o <br />supe <br />on <br />n <br />o <br />n <br />I <br />es <br />g <br />tin <br /> W assure that qualified personnel properly {lather and es aluale the information <br /> suhmilt d. Uased un my inquin of the person ,.r perc.ms who manage the i%om. <br /> or the persons dirmtl? respgatsihle for gathering the inrormalion, the information <br /> suhmilled is, to the hest or to, knowledge and Wier. true. accurate, and complete. <br />Ih <br />t th <br />ifk <br />l <br />lti <br />% <br />hmitti <br />rape i <br />f <br />tio <br />I <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am aware <br />ere are s <br />gn <br />an <br />pena <br />es <br />or <br />u <br />ng <br />n <br />orma <br />n, <br />a <br />including the prnsihilflr of fine and imprisonmrnl for km.wing siolations. <br />I OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br /> <br />(Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. . . This is a 4-part fonn.