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PERMITTEE NAME/ADDRESS /Include Filediri \mn, /,,rau,n y !nlf, r, nr, 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 /> <br />NOTE: 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 /> <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtiQ under penalq of law that thi%document and all auarhments were <br /> <br />ra islon in accordance wills a ss Hem deigned <br />re <br />ared under m, dir-lion or su <br />TELEPHONE <br />DATE <br /> p <br />p <br />p <br /> to a-ure that qualified personnel properi% gather and rsaiuale the information <br /> suhmitted. Bawd on mi inquin or the per.,m or prison. who nwnage the ssslem. , <br /> or Ihox prnons direclh responsible- for gathrring the inforn>alion. the infurniation <br /> %ubmilld is. to the hest of my knowkdge and belief, Inar, accurate, and complete. <br />s f <br />s <br />h <br />I <br />sw <br />th <br />t th <br />nir <br />anl <br />e <br />lti <br />itti <br />fil <br />i <br />fo <br />atio <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am <br />am <br />ere am s <br />g <br />w <br />p <br />rm <br />e <br />or <br />u <br />m <br />ng <br />ar <br />n <br />rm <br />n. <br />a <br />including the p,nsibility ,d fine and imprisonment [or knowing siolations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3x'99) Previous editions may be used This is a 4-part form.