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PERMITTEE NAME/ADDRESS dnclude Farility %amr 1-au -j ij Ni/feet. <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <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 /> <br />EX OF <br />TYPE <br /> <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 /> 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER 1 cenif) under penalty of I.- dial IN, A runwnt and all attachments were <br />d <br />di <br />i <br />i <br />d <br />i <br />d <br />d <br />t <br />---- <br />? TELEPHONE GATE <br /> prepare <br />un <br />er np <br />rtrin,j-r .uprrs <br />nn <br />n accor <br />s <br />mtce with .-tern <br />cvignav ? _? <br />, <br /> to wore 1huf qualified pe-,mtcl prnprrh gather and -duate the information <br /> %uhmilled. Rased nn mr iugai of the Iw-rwm or perwms who manage the pstrm. <br /> or those IK•r.on, dire -lie t -pmolde for gathering the information, the information <br /> whmitlyd K. to the X <br />of m> kn-ledge and w <br />ier. true. accurate- and complete. <br /> I am aware that there art- ignifcani penalties for suhmilling falsr inrormution <br />em <br />r SIGNATURE OF PRINCIPAL EXECUTIVE <br />r <br />TYPED OR PRINTED . <br />including the possihililr of fine and imprisonment for knowing sitdatioms. OFFICER OR AUTHORIZED AGENT <br />. AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. of ` This is a 4-hart form.