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PERMITTEE NAME/ADDRESS NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO L_ F-7 <br />MIA <br />(SL <br />L <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 <br />I REQUIREMENT i 1 -:?` • ' <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 ccruN, under penalty of law that mic document and all attachments uere TELEPHONE DATE <br /> prepared under m} direction or supcr ision in acumiancc N nh a system designed <br /> <br />["L Jet - '5-4e C to assure that qualified personnel properly gather and evaluate the information <br />th <br />t <br />m <br />b <br />i <br />f th <br />h <br />d <br />B <br />d <br /> e person or perms w <br />o manage <br />. <br />mitte <br />. <br />on nh} hnqu <br />n o <br />e sys <br />e <br />su <br />ase ???- _. <br />? <br />1 <br /> or those persons directly rr= nt,,able for gathering the udornation, the mfonnauon . <br />. <br />- <br />`t ?_ <br /> <br />, submitted is. to the best of m} knowledge and Imelief, true. accurate, and eornplete <br />f <br />l <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ 7, <br /> I am aware that there arc sigruticant penalties for submining <br />a <br />se <br />nformation <br />f <br />k <br />i <br />h OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />R PRINTED <br />TYPE or <br />nowing r <br />o <br />uions. <br />including the rossibdity of line and impri onnicnt CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editors may be used. T(U3 is a 4--part fonn.