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PERMITTEE NAMEIADDRESS,1,,, 1:e :;::•. `.,,n:; (-, ,n.n ;r (.;,;r, n.:r NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before conipletinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT c'111":' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t- 3r, h s tt #i •r t" RE"OJ?T D. 5 wJ PA15 <br /> REQUIREMENT ;JOPA LA <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT ' OFc ( ; <br /> SAMPLE <br /> MEASUREMENT <br /> i ;i <br />PERMIT <br />REQUIREMENT RP ir-T <br />;•IAX f-.: -_ st li f' . ,. . ii itit x ?{ 7 n #x• a r# iN <br />- <br />?ti <br /> <br />SAMPLE <br />MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cenili under penaln of law that this do umenr and all auaclnnents were TELEPHONE DATE <br /> ared under my direction a supers tsrcm in actor hence wnh a +ysicm tlcsiyttcd <br />re <br /> p <br />p <br />[n assure that qualified personnel pruperh gather and evaluate the infornmuon <br />submntcd. Baud on my utgmn of the person or per ins who trsinage the system. <br />the mfomtauon <br />the inf i-ntation <br />12+ <br />th <br />nn <br />d <br />l <br />ibl <br /> <br />t <br /> . <br />y respons <br />t ga <br />g <br />ireel <br />e <br />e <br />or those peruns <br />submitted ts. to the hest of my knowledge and lxher. true. accurate. and complete SIGNATURE OF PRINCIPAL EXECUTIVE <br /> lain aware that there arc significant pettdlue-s for submarine, false information. OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the possibility of fine wW imprisonment fir knowing stulauon; CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all affachments here) <br />RECIP EVENT 6UBJGt_:T TO BURDEN OF PROD! <br />17 TF1 TN?'-- 'DTVfR10N W:'?iIN 46 F!vl1Fi:= <br />PAGE OF <br />T•hf,'isa 4-part form. Form 3320-1 (Rev. 3.'99) Previous editions may be used.