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PERMITTEE NAME/ADDRESS (Include Facility Menu /lu,,uo m a Nitlcrrnt <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 />IT,QVTT <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 I( ,? l?( <br />1. l <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 cerliO node( 1- ill, -4 luw that this docuutrnt and All atta( hment, were TELEPHONE <br />' DATE <br />, =ys <br />pn•pured under in-Ii rection or suprrsi,om in -orrhmce with a,). designed <br />- 1 to ascurr that ymdified pemonnei pruprri' gather and enduate the information - ?- - _ _ <br />submitted. Hasrd on m) inyuln o(Ihe pa•rwn or pers.mc who manage the yctem. ? ? • __?-?- -. <br /> <br />Is responsible for gathering the information. the information <br />ur those parsons direct <br />- submitted i, to the M•ct o(m) knowledge and belief. trot. Act undo. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />j <br />TYPED OR PRINTED I am aware that them are significant Penalties for submitting false information. <br />including the p, Bolin of Fine and imprisonment for Looming aiolations. OFFICER OR AUTHORIZED AGENT AREA D NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here <br />T <br />EPA Form 3320-1 (Rev. T99) Previous edtiOm may be used. - 11i5 IS' a 4-part fOrnl.