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PERMITTEE NAME;ADDRESS,h,,::,d. h.o- drr :!:n.,,.,:r. <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 L_ I <br />ra t r` <br />(LJ l <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />Of SAMPLE <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 IF; ; <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = . <br />t: REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME MTLE PRINCIPAL EXECUTIVE OFFICER 1 .entfy under penalty of law that this d-urrncnt and all anachments were TELEPHONE DATE <br />1 reprised under my direction or aipenisnm in accordance with a system designed <br />_ <br />t., -sure that qualified personnel properly gather and evaluate the information _ <br />uhmined. Baud on my mqutn of the person or perm ns who manage the system. <br />the information <br />or those persons dtrecth responsible for gathenng the information <br />, <br />d ' <br />complete. <br />?? a submined is. to the best of my kru-wlcdge and Wier. true, ac:urutc, an <br />ak <br />i <br />f <br />. SIGNATURE OF PRINCIPAL EXECUTIVE C- f= <br />or submitting t <br />ntornan"n. <br />I am awurc that there are significant penalties <br />e <br />! <br />h <br />k <br />i <br />i <br />f <br />d <br />( <br />O OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />rig an <br />nr,wmg y <br />n <br />ar <br />ons <br />R PRINTED ncluding the pusv <br />ihn of <br />imprisonment <br />or <br />TYPED CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,99) Previous editions may De used. D a0 1 ; ; This is a 4-part fonn.