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PERMITTEE NAME/ADDRESS 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 />Form Approved. <br />OMB No. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT f <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 />NAME/TITLE PRINCIPAL EXECLMVE OFFICER I cerrif' under pshtalty of law that this document attd all artachrm-nts wcr TELEPHONE DATE <br /> prepared under my direction or supemsmn to accordance with a scst ern dcsipncd <br />l - - to assure that qualified per>,atnd pnrpcrly gather and evaluate the tnlormanon <br /> wbmittYl. Based on my ntymn of the person or person who manage the wstcm. ;% "sue <br /> or those persons dtrecth respcimiblc for gathering the infotmation, the mfonn.t it <br /> uhnun •d i,. to the hest of my knossledge and beliel. true, accurate. and complete. <br />- are th:u th <br />r <br />ar <br />¢nlticant <br />enaltie <br />for submmtn <br />ialse mtormauon <br />I <br />n SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />YPED OR PRINTED ? <br />ti <br />e <br />e <br />c si <br />p <br />s <br />g <br />' <br />i <br />h <br />h <br />f n <br />f <br />k <br />l <br />3 <br />fi <br />d OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />T r_ t <br />ons <br />m. ,:• <br />e Iv ,,: <br />i <br />t} o <br />ae an <br />impn,onment <br />or <br />now ine vio <br />at I CODE <br />I.VMMr-N IJ Ar41J r-Art-MINMI wrr yr MINT VI%JL-P% I lvlNA tnarwrv"v w at, auac,rvmervw ncrc/ <br />iN <br />EPA Form 3320-1 (Rev. 3,189) Previous editions may be used. ("D 1 44 • : This is a 4-part form.