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PERMITTEE NAME/ADDRESS /Include Facility \atm-lbwanon i(Ni! rtyw <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 /> 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 /> <br />PERMIT 7' 1 <br /> REOUIREMENT <br />NAME)TITLE PRINCIPAL EXECUTIVE OFFICER I eertif.i under ltemdt. to( law that this document and all attachments were <br />d <br />i <br />d TELEPHONE DATE <br /> es <br />gne <br />prepared under ms di-tion or superskion in aecordance with o ry%irm <br /> to assure that yualiftrd Personnel prop•rls gather and rsaluate the information <br /> submitted. Hard on mr inyuin of the 1werson or persons who manage the system. <br />' <br /> or those persons dirrdh responsible for gathering the information, the information <br /> suhmitted is. to the lw•st of m) knom"L and Wirt. true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there am significant penalties for submitting false inrormatiem. <br />including the F-sihilits of fine and imprisonment for knowing siolrtions. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments nere) <br />IF CLAIM APPROVED BY WOCIL)i, <br />4-9 FOR BURDEN OF FROOF <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. 'rhis is a 4-par( form.