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PERMITTEE NAME/ADDRESS (include facilui Nome l -arum if Pilfrrimt- NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION 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 <br />OF SAMPLE <br /> EX Y <br />I TYPE <br /> ANAL <br />S <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br />+ <br /> MEASUREMENT <br /> <br />PERMIT r/ <br /> REQUIREMENT r?tf1P?T?' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT rt <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT " r <br /> <br /> SAMPLE zc, l•?c <br /> MEASUREMENT <br /> PERMIT PT. <br /> REQUIREMENT <br /> <br /> ( <br /> SAMPLE <br />?1 )7:4 1 n?SZ? <br /> MEASUREMENT <br />• <br /> <br />PERMIT <br />t) ; <br />PUN <br /> REQUIREMENT <br /> SAMPLE <br />) 4 <br />/ <br />i <br />r?) <br />(,QJIB <br /> MEASUREMENT ] <br />PERMIT < < - ._ l' l • .. <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of In,, tint this document and all attachments Mere TELEPHONE DATE <br />prepared under my dirccueu - sol enisim+ in accordance with a .yaem deigned - - ,_ <br />`` to assure that qualified prn•.nnel properl% gaihcr and csaluale the information <br />mrc id the person or W-m, who manage <br />s <br />bmitt <br />Based on m <br />in <br />d <br />. <br />y <br />y <br />u <br />e <br />- <br />• ' <br />or Ihosr lxrs.ms dinYtly rnlw,nsitdr for gathering the infnrnmiiim. the mrnrmnt+on <br />?r <br />s+thmittA is. In the hest of nn knowledge and brlu•f. true. accurate. and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />C <br />-• I um aware that threes are rcndicant pcnaltie. for+ubmittmk falx information. <br />I <br />E AREA <br /> d i <br />risonment for knowing siolations <br />vbilit <br />rG OFFICER OR AUTHOR <br />ZED AG <br />NT DE NUMBER YEAR MO DAY <br />TYPED OR PRINTED • <br />i u <br />nr an <br />mp <br />including the pw <br />COMMtN 15 ANU tAI-LANAI IUN Ur- ANT <br />Incrcr crwc ao ouQa......c..w ..c. ?/ <br /> <br />')Iris is a 4-part farm. ~""° 1 <br />EPA Form 3320-1 (Rev- 3/99) Previous editions may be used.