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PERMITTEE NAME/ADDRESS flnclude Facility Xame'l-ar eta it Ut/frrrnh <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 />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />R•Ot-)TT <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />?? <br />•1L <br />t ? <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 te,Gh ... t tw oa t...f law that thi. d anmrm and :dl auachmutl` were <br /> <br />d <br />d <br />ti <br />i <br />di <br />i <br />l <br />i ? <br />yyyy <br />TELEPHONE <br />DATE <br />- <br />•. t .- - prepare <br />er m, <br />rec <br />on nr wpen <br />un ht accnrt <br />antr w <br />un <br />+ <br />th u.}dem tkcigtled <br />w a,.tlrf that qualified W -mid properl% gather am$ a aln tt the Inform.timl <br />I / <br />j <br />?- - - - <br /> 4lhmttled. R-d on mt intluir. of the fa• if or tiemim.. who manage The -irni, <br /> or thrrta• per.un, direcll> rrspmsihk for %alhering flit inf rm wm, the mforntatinn _ _ _ ) <br />?• whmttted ic, fo tht lied of m1 know IML • and belief. free, a-curufe. and rumple te. ?_ -• - (- i <br />f ,? / <br /> I am aware that there are cigttiff lint prnultits for %uhmdling fal.e mformalion SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED , <br />itteludiug the p-ihihty of fine amt imprisonnn•nt for knowing riolulion.. OFFICER OR AUTHORIZED AGENT AREA CODE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. Ws is a 4-Part form.