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PERMIT-TEE NAME/ADDRESS,hi. !!-', 1.-hr In ,I, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <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 />REILAt, <br />NOTE Read Instructions before completinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />• _?i rtil MEASUREMENT <br /> PERMIT <br />L REQUIREMENT <br /> <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 certify under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under my dire:uon or supentston to accordance «nh a system deigned <br /> <br />'L r to assure that awthtied personnel properly gather and evaluate the mtormanon <br />, r ; iut+nutted. Based on my tnyuiry of the prison or persons oho manage thew <br />stem. <br /> <br />i <br /> or thou persms directh responsible for gathering the information. the information <br /> submitted is. to the best of m} Anossinigc and hehrf true, accurate, and complete- <br />i <br />f <br />b <br />al SIGNATURE OF PRINCIPAL EXECUTIVE , 1 r' ! ,? <br /> k information. <br />I am mrarc that there are significant penalt <br />es <br />or su <br />mitting t <br />f <br />d <br />i <br />i <br />f <br />k <br />i OFFICER OR AUTHORIZED AGENT <br />EA <br />AR U <br />NMBER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />TYPE OR PRINTED im o <br />mprisonment <br />noµmg %io <br />anons. <br />including the possth <br />f <br />ne and <br />or CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLAI IUNb (Hererence an arracnmenrs nere) <br />4iR r'F:Er T0 !r It,. c nG. .-3 FOR ???f?l;i ,cl•si '?T? <br />This is S 4- art fonn. PAGE OF <br />EPA Form 3326.1 (Rev. 3/99) Previous edrttons may be used. i_ jY _