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PERMITTEE NAME/ADDRESS dn,Nde Facifirr h'amr Lo,arrnn ifngjerenri <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-OOD4 <br />i '; -AN <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 J 1 U <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 r .. .: <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />- r_ . • - MEASUREMENT <br /> <br />PERMIT r'f <br /> REQUIREMENT <br /> SAMPLE <br />- MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME7nTLE PRINCIPAL EXECUTIVE OFFICER I .entfy under penalty of Iaw that this document and all attachmenrs scrc TELEPHONE DATE <br /> prepared under my direction or supen tsnrn in accordance with a system destf nod <br /> <br />S? " r to assure that yualttkil penotutel properly gather and cs'aluate the information <br />wn of the petson or persons who manage the scacm <br />submiued Ba <br />ed tin my m i - <br />r " r e <br /> . <br />g <br />s <br />or those persons directly rc,ponmble for gathering the mhtrntation. the information r <br />_ d <br />l <br />k <br />i, t L ,; comp <br />ete <br />nowledge and behef. true. accurate. an <br />suhmiltcd is. to the test of mN <br />ti <br />h <br />tt <br />fal <br />u <br />h <br />f <br />t <br />lti <br />f <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br />` <br />` er su <br />ortna <br />om' <br />! am aware t <br />at t <br />ere are signi <br />ican <br />pena <br />es <br />mt <br />tng <br />se rn <br />ih <br />h <br />• <br />f <br />k <br />i <br />i <br />l <br />h <br />f <br />i <br />d i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPED OR <br />PRINTED now <br />o <br />e poss <br />t <br />... <br />t <br />ne an <br />mpnsorm-cni <br />or <br />ng v <br />ations. <br />including t <br />i CODE <br />GUMMLN 15 ANLI tAI1LANAI IUN Ut- ANY VFULAI IUrvJ (riererence nu <br />FOR !0YF.. 24HR FRc <br />nerel <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. , . _ This is a 4-part fonn.