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PERMITTEE NAME/ADDRESS tlncludr FaciiSty Name 1 ,-awn wn it Gtffrrenl ? 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 <br /> <br />MH <br />NA 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 NQ, 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 /> 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 certif-, under prnalry of law that lhi, document and all atlachmrnts were TELEPHONE DATE <br /> prepared under nn direction or supeni,ion in accordance with a system designed <br /> to assure that qualified presonnel properh gather and esaluate the information <br /> submitted. Bard an - inquire of the person or per,ons who manage the %i Hem. <br /> or those pennns directh resp n%ible ror gathering the information. the information " <br /> submitted is, to the hea or m% knowledge and belief. true. "curate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am aware that tlwm are sianiricant penallirs ror submitting false inforntallon, THORIZED AGENT <br />FI AREA <br />TYPED OR PRINTED including the por %ibilitt of fine and imprisonment far knowing siolalioa OF <br />CER OR AU OD NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />NS tt EFFECT", s.RDWTH AND <br />EFF 13'TW4 TEST R• CONTROL <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.