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PERMITTEE NAME/ADDRESS (include Pacinry.\omdlacatum if rlifferen/1 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <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 SAMPLE <br /> OF <br />TY <br /> EX ANALYSIS PE <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 cer6f% under penult) orlaw that this document and all attachment, wen' <br />r <br />Li <br />i <br />d <br />l <br />di TELEPHONE DATE <br /> <br />- l_ prepa <br />um <br />er m.s <br />nn nr wpcr, <br />e <br />rv <br />,iun in acewrdancr with u »stem de,igmd <br />to a-ure that qualified f-m id properl% Rather and a,aluate tle information .. <br />, Rased on m <br />ubmitl d <br />in <br />uire of the <br />rrvm ur <br />rrsmts whn m <br />e the -le <br />n . <br />i <br /> . <br />% <br />q <br />p <br />p <br />a <br />ag <br />m. ? <br /> or thmr prrnon, dinYtls re,ponsiblc for gathering the information. the information - - . - , <br /> <br />V <br />submitted ic- to the 1t-a of m> knowledge and belief, true. accurate. and comp{eta ` <br /> <br />I am ..are that there are significant pcnaltio., fur ,ubmittlng false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />including the peoihilih of fine and imprisonment for kn-itrg siolatiuns. <br />OFFICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />ANU tAFLAIVAI IUN Ul ANY VIULAIIUIVJ (Pfererence all arracnmenrs here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-Part form.