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PERMITTEE NAMEIADDRESS Itndude Hurifin \am, el an- if bdfrrrnl, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <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 />P. <br />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 /> <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I -i-tifc under p roihi of law that this doavnamt and :dl almchments were <br />tio <br />o <br />s <br />enisio <br />o <br />with a syst <br />si <br />d <br />de <br />di <br />e <br />i <br />m <br />d <br />d <br />n <br />d TELEPHONE DATE <br /> prepare <br />un <br />r nn <br />r <br />c <br />n <br />r <br />up <br />n <br />n <br />x <br />r <br />ance <br />em <br />e <br />g <br />e <br /> in assure that qualified personnel proper-IN Xalln•r and esaltwle the information <br /> submitted. Rased on m) inquiry of the person or persons who manage the system, <br /> or those pennns directly responsible for gathering the information. the information - - <br /> submitted is, it, the tw.,4 or my knowkdge and belief. true, accurate, and complete. <br />b <br />itti <br />ti <br />I <br />h <br />h <br />i <br />if <br />l <br />i <br />f <br />r <br />i <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am aware t <br />at t <br />ere arc s <br />gn <br />icant Pena <br />t <br />es <br />or su <br />m <br />ng <br />a <br />se <br />n <br />orma <br />on. <br />including the pmsibilip of fine and imprisonment for knoming siolalions. OFFICER OR AUTHORIZED AGENT AREA <br />COD NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3/99) Previous eftons may be used. 'his i5 a 4-Part form.