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PERMITTEENAME/ADDRESS h:, hide Fuc-i1rn*Aamc'[.xartonrfUiifetentl <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 /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION I NO, FREQUENCY SAMPLE <br /> <br />EX Of <br />TYPE <br /> > <br />< ANALYSIS <br /> - AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i'1 i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT : 1-; t; J'- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT s <br /> REQUIREMENT <br /> SAMPLE r <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; <br /> REQUIREMENT T: <br /> SAMPLE ; <br />'* F, r MEASUREMENT <br /> PERMIT r <br /> REQUIREMENT 1 <br /> SAMPLE t <br /> MEASUREMENT <br /> PERMIT I? r c ,Jn . <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccnil) under pen:drr of law that this dL%:wnent and all attachments were <br />d <br />d <br />di <br />i <br />i <br />i <br />d <br />i <br />d <br />h <br />d TELEPHONE DATE <br /> prepare <br />un <br />er my <br />re tton or superv <br />s <br />on <br />n accor <br />ance w <br />t <br />esigne <br />a system <br />?-+ LL/.} t ! to assure than qualified pcrvonnel properly gather and evaluate the tnformatuat <br /> submitted Based on my ingwn of the person or perwn, who manage the system. <br />? <br /> or thow persona directly reslxatsible for gathering the mtomatitn. the information < ? <br />??•' '`"?" <br />l ? ] t. submnt, is <br />to the best of rm l n,,w lcds;c and Fnc?f. true a-iratc. and complete G <br /> . <br />m aware th <br />t th <br />r <br />r <br />r,- SIGNATURE OF PRINCIPAL EXECUTNE <br />TYPED OR PRINTED a <br />a <br />e a <br />c <br />e <br />pr n i. 1 i 'u <br />including the possibility o t, n. OFFICER OR AUTHORIZED AGENT ARE <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. c_)() 1 n r- This is a 4-part form.