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PERMITTEE NAME/ADDRESS Ilnrlude Farilits.Vome/l orurioe ifDifferrnl, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2046-0004 <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 f <br /> REQUIREMENT _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalh of law that thisd,avntent and all atlarhmrnl%weer <br />d <br />d <br />di TELEPHONE DATE <br /> prepare <br />un <br />er nn <br />rection nr supenision in accordance with a -ten, designed <br /> to assure that qualified We innel proper t galher and esaluute the information <br /> suhmitied. Ruled on m) inquiry of the prru,n nr peru,as who, manage the systrm. <br /> or thine penons di-e d% responsiMc ror gathering the informati(on, the information <br /> submitted Is. u. the lest of my knowledge and hdkf, true. accurate, and complete. <br /> <br />I am aware that there are significant penalties for submitting false infurmatit. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />including the possibility of fine and imprisonment for ktwwing siolations. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />UUMMCIV I sb AIVU r-AI LAIVA I IUIV Ur AIV T <br />an arracnmenrs nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.