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PERMITTEE NAMEIADDRESS (Indudr Facility Namr/l."ation if fkifferent] <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 />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 /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eerur. under penall- of law that this document and all attachmrnta.err <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> ance . <br />prepared under my directkm or -Per%i,um in accor <br />t <br />a system <br />es <br />gne <br /> It, a-re that qualified pe-nnel pngmrit gather and rsaluate the information <br /> submitted. Based on me ingnirs of the pet-ai or per on%.ho manage the -tem. <br /> or them Mr ores direcll) r-I.- ble Pw gathrring the information. the information <br /> suhmitleal is. In the best of mq k-%ledge and belief. true. aecurutr. and complete. <br />ti <br />ir <br />- <br />k <br />h <br />i <br />i <br />f <br />l <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED ti for w <br />on. <br />I am...re that there are.ign <br />nl penalt <br />m <br />tt <br />nit <br />a <br />se <br />n <br />orma <br />k <br />including the fansibilits of firer and imprisonmrm for Ano.ing siolations. OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />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. This is a 4-part form.