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PERMITTEE NAME/ADDRESS (include F'ucilih :1nln..l.,, wr,n it mit n ruf 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 YEAR MO DAY YEAR MO DAY <br />FROM TO <br />._ i <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 SAMPLE <br /> OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />MEASUREMENT <br />T / r- <br />- " I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / <br /> MEASUREMENT <br /> PERMIT rsiif <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREM ?r <br /> ENT <br /> PERMIT <br /> REQUIREMENT ? <br /> SAMPLE <br /> <br />MEASUREMENT _ <br />S <br />? <br />= ,4- •6 <br />?- <br /><7 <br />??! <br />t- AC, <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />t?A <br />NI <br />A <br /> r <br /> PERMIT a r.i <br /> REQUIREMENT <br /> SAMPLE <br />EASUREME ??{{ <br />`?' <br />`21 <br />In <br /> M <br />NT <br /> PERMIT <br /> REQUIREMENT <br />NAMErrlTLE PRINCIPAL EXECUTIVE OFFICER I certif. under penalty •.. 1- Thal this d-unn•nt and all attacbments werr TELEPHONE DATE <br /> <br />\ <br />_ prepared untie( ms dit- ii,m nr wfa ni.ion in accordume with a astern desigmd <br />? <br />) 1 <br />• <br />?^ <br />ti <br />I <br />1 <br />' <br />- <br />?` : '' <br />? 11) a-re that qualirred I•'nonnel properh gather and esaluatr the information <br />. c <br />! <br />t <br />_ <br />- <br />C <br />: <br />• <br />__ %ubmiucd. Ba ed on my mquin of Iht• person or pr-n% who manage the s. stem. -------- <br /> <br />\ or Ih.we per-wt, diracll. -jp risible fur s--al hering the information. the information - - - . - , <br />t <br />- - <br />• submittal n, to the hnsl 4 tm knowledge and 1"0. toe, wrnrale. and rnmpkk. ?'. c- <br />? <br />• <br />_ <br />" I am aware that there an i <br />nifiicunt <br />wnallits for s <br />h <br />W <br />itti <br />i <br />f <br />rmati SIGNATURE OF PRINCIPAL EXECUTIVE rV I <br />) , i l <br />TYPED OR PRINTED j <br />g <br />u <br />m <br />ng <br />w <br />n <br />o <br />on. <br />imiuding Iht• ptnsibifih d fine and impri-oment for knowing violations. OFFICER OR AUTHORIZED AGENT <br />I AREA NUMBER <br />CODE YEAR MO DAY <br />1 J AIYIJ CArLAIYA I IVN Vr AM T <br />an arracnmenrs nere) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This is a 4-part form.