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PERMITTEE NAME/ADDRESS (Include tat diti fain, 1-an n'l lhlf rf <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />W TO UNNMD IR f B/HU3DARD CREhli <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />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 penalty of law that this denunnem and at altnchments were <br />d <br />with <br />d <br />d <br />di <br />i <br />i <br />i <br />i <br />d <br />t <br />i TELEPHONE DATE <br /> gne <br />on or superv <br />on <br />n accor <br />ance <br />em <br />prepared un <br />er tn% <br />rect <br />s <br />es <br />a sys <br /> to -sure that'l iiried persemmi properly gatM-r and etal ate the information <br />of th <br />s who m <br />the % <br />Hem <br />h <br />d <br />n <br />in <br />i <br />r- <br />ru <br />na <br />i <br />d <br />B <br />or - <br /> pe <br />' <br />tte <br />. <br />ase <br />o <br />m) <br />qu <br />re <br />e p <br />n <br />m <br />a <br />ge <br />. <br />su <br />m <br /> or thine person, direct) respemsibir for ttathering the information. the information <br /> suhmiued is. to Ihr by t of my knowledge and hefkr. true, accurate, and complete. <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there are significant penalties ror submitting fidw informat <br />on. <br />inchtding the p,nsihiliq of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-Part fomi.