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PERMITTEE NAME/ADDRESS !include Facihiv %am, l „•, ; ,,,; it Nijt, r w <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 NQ• <br /> <br />EX FREQUENCY <br />OF <br />NALY <br />IS SAMPLE <br /> <br />TYPE <br /> A <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE r, J- t , ' kL= <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <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 certdh waver penatts of l.n, mat mu d,wument and Al attachment. were <br />prepared under my dir i, or . jrier lion in accordance with a %*Aem designed - TELEPHONE DATE <br />- - _ l <br />- - ? .._ <br />' to as-re that qualified pr, -noel propert' t gather and -Male the infnrtnati,m <br />suhmiued. Nawd un m? inq u f lhr prison ur penons who manage the s?>tem. <br />or thaw pen,ma direcdv n,p•n.,hle for gathering the mrar-mation, the information <br />-- <br />- - - ?? -?_ -_- <br /> <br />- <br /> uhmitted is• to thr host td n„ km -ledge and Wief, true. accurate. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE , J <br /> I am aware that them am,,Qnifi.ant penultirs for submitting falw information, NT AREA <br />TYPED OR PRINTED nehding tM gn.ibility of Gw amt imprisonment fur knowing .iulutiuns_ OFFICER OR AUTHORIZED AGE <br />I NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ail attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. 'C nisis a 4-part form.