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PERMITTEE NAME/ADDRESS !include Pacifier Name/llxodon if lhfferenll NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <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 r Y?' I ?I 1L <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I ' <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 /> <br />/ TELEPHONE <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I crrtit% under penalu ,d tow that thi, documrm aml all aua•hmems were <br />DATE <br />P,parrd under m-i din•clinn or %ut-ision in accordance with a . stem designed <br />Iu awurr that qualified p-nm•I properh gather and evaluate the information <br />ubmiurd. Naxd un m1 mquin of the prnon ..r fx•r.onc who manage the -tem. <br />or thou- persons dim91% rr.ponstMr for gathcnng the information, the information <br />`J <br />- cuhmitl d n, t the brit of nn kn-ledgr.md helieL true. wcurute, and compkie. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are significant I-allies for submitting false mforrnatiotr. <br />RI <br />ED AGENT <br />FF <br />ER <br />R AUTH AREA <br />TYPED OR PRINTED including the fan+ibilits or fin, and impri, amen for knowing violations. O <br />IC <br />O <br />O <br />Z ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Hererence an arracnmenrs nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used TI1F? lti a 4-part form.