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PERMITTEE NAME=DRESS rlnclude Facilin Nmre'Locarlon r/nif mnrl <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 <br />OF SAMPLE <br /> EX 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 1'. <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I -rtif? under penalty of law chat rtus d-rumrnt and all duachinmL were TELEPHONE DATE <br />pre cored under my direction orrupen r,!on to accordance with a system designed <br />r• to assure that qualified personnel properly gather and ecahuwtc the information <br />s who m <br />C <br />LL?ilS f <br />na <br />t <br />f <br />h <br />th <br />b <br />d <br />d <br />a <br />ge <br />e sys <br />o <br />on my mgwn o <br />t <br />e person or person <br />em. <br />su <br />rmtw <br />Base _ <br />or those persons directly re rxi ,siblc for gathering the information. the information <br />submitted is. to the hest of my knowledge and beLct true, accurate, and ; omplrt`' <br />na <br />l <br />f <br />h <br />f <br />i <br />( SIGNATURE OF PRINCIPAL EXECUTIVE ) <br />/ <br />L ^ ?, <br />m <br />icant prnalues fx u <br />ng <br />a <br />se <br />n <br />om:.!! r. <br />I am aware chat there are signi <br />k <br />i <br />f f <br />l <br />" OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />nawm@ c <br />n <br />atto <br />ine and impnxromcn! h.! <br />TYPED OR PRINTED mauding the pos,tbthq o CODE <br />COMMENS AND EXPLANATION OF ANY VIOLATIONS (Re/erence a!I attachments here) <br />;. 14 <br />EPA Form 3320-1 (Rev. 3199) Previous eddions may be used. 001 4 _, ?h/9 IS 3 4-j>aR fUinl.