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PERMITTEE NAME/ADDRESS rlnrlude Farilirr Yamn'I naui on tf Dif ,rrnrll NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION 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 SAMPLE <br /> <br />EX OF <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 />T <br />I <br />? <br />AL3 <br /> MEASUREMEN , i, <br />•? ?? <br /> <br /> PERMIT .. :.- - <br /> REQUIREMENT <br /> SAMPLE <br />- MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />S <br /> MEA <br />UREMENT <br /> PERMIT . -T- `-. :. .. - <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cerlif) under penalty of law that this document and all attachments ..ere <br />ti <br />i <br />i <br />d <br />i <br />h <br />d <br />d <br />di <br />i <br />d <br />i <br />d TELEPHONE DATE <br />_ <br />1 Prepare <br />un <br />er ms <br />on or supen <br />ance w <br />es <br />rec <br />s <br />un <br />n accor <br />t <br />a -t<m <br />t;m <br />to assurr that qualified per.onnel properh ¢alher and e•saluate the inform:rtion <br />suhmitted <br />Rased on nn inyuirs or the person or Person, w ho manage llw aratem / <br />?- •-?- f - <br />`- <br /> . <br />. <br />ur Ihwsa• person, direcds responsible for sm1henng the informatiom the mfonnatiion , _ <br />-_';•_ - - - _ ? <br /> suhmitt d is, to the hra of tm knowledge and tx•lief, trur, an•urate. and complete. f (. ? i ) <br />' I am aware Thal there are aiwiiricani penalties for submittin <br />false information SIGNATURE OF PRINCIPAL EXECUTIVE - _ r <br />TYPED OR PRINTED g <br />. <br />including the p-ibilits or Fine- and imprisonment for knowing siolations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3195) Previous editions may be used. This is 3 -Part form.