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PERMIT-TEE NAMEIADDRESS tlnclude Facilitc.\'ame/lorafion if Uiffrrenr) <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 />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 /> 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 />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I errtifc under prnalt . of taw that This dceumrnt and all attachment% were TELEPHONE DATE <br /> Prepared under m) direction or supersision in -cnrdrner with a system designed <br /> I. a-re that yualirted personnel prulied, gulher and evaluate the information <br /> suhmined. Rased out m% inquire of the I*- or peru s who manage the system, <br /> ,or thnsv Imrsons dirmtit responsible for gathering the information. the information -' <br /> suhnnited is, to the hest of m? knowledge and helirL true, accurate, and caanplete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that then arc significant penalties fur suhmining rake information, THORIZED AGENT <br />F <br />I <br />A AREA <br />TYPED OR PRINTED including the possibility of fine and imprisunment for knowing siotatiun` O <br />F <br />CER OR <br />U ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA nONS (rre?erence an anacnmenrs nere) <br />EPA Form 3320-I (Rev. 3199) Previous editions may be used This is 8 4-part form.