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PERMITTEE NAME,'ADDRESS ilwcludeFacilin %ameLocation WDiflerrnrr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION. Y ` <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 />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 ! i C, F <br />_ ;. <br />J REQUIREMENT <br />If ..r.? ).t . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 /> <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under my direction or supen t,ton to accordance with a system designed _ <br />1t <br />?! O rr i C-Q ! ' ' } e = ! r to assure that qualttied peponnel rroperly gather and evaluate the information <br />h <br />f <br />h <br />h - - -: - <br /> e perxm or persons w <br />o manage t <br />e system. <br />submitted. Hascd on m} inquiry o <br />t <br />?- <br /> or those persons directly resporimble for gathering the information. the mfomtation <br />n C submitted is, to the best of my know-Icdge and belief. truo, a curate, and complete <br />f <br />b <br />t <br />k <br />i <br />f <br />t <br />h <br />fi <br />l SIGNATURE OF PRINCIPAL EXECUTIVE S <br /> ion. <br />at there are igni <br />cant pena <br />or su <br />mitting <br />a <br />se <br />n <br />orma <br />I am swarc t <br />ties <br />i <br />o <br />k <br />l <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED ne and imprisonment f <br />r <br />n-ing vio <br />ons. <br />utcludmg the pos»hihr. ,,t f <br />at CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />This EPA Form 3320-1 (Rev. 3;99) Previous editiors may be. used. IS 8 -(Ydpt form.