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PERMITTEE NAMEiADDRESS,L•:, ;,,,lr <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 />r- I <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 s f' i "' _ c' T a <br /> REQUIREMENT _ <br /> SAMPLE <br />_ MEASUREMENT <br /> PERMIT OR r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -r <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/"nTLE PRINCIPAL EXECUTIVE OFFICER I ecnif% under penalty of law that this document and all attachments Acre TELEPHONE DATE <br />prepared under my direction or supcroston in accordance with a S%SLLnt designed <br />it to assure that qualified personnel properly gather and c%aluatc the tntimn.nion __ --• <br />r <br />e <br />submittal. Rased an my inquiry of the person or perums who manage the system. <br />' <br />- - <br />or those persons directly responsible for gathering the information, the infotnwtion / <br />C submitted is. ro the best of my knowledge and bchcl'. true. accurate. and comploc. SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ <br /> am aware chat there are significant penalties for submitting false information. <br />1 <br />i <br />l <br />i <br />f <br />k <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DQY <br />TYPED OR PRINTED now <br />ng s u, <br />at <br />oas <br />or <br />including the possibility of tine and imprisonment CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />0003 Thi3 isA 4-part form. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.