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PERMITTEE NAME/ADDRESS tlrn hide dDilleir"n <br />NAME <br />ADDRESS F <br />FACILITY <br />LOCATION <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 I ±? <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 /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = - i _ : • ,,: F-P aR f . u-,' T r• 7? <br />t) REQUIREMENT ;'•_ L` r 1 L Y r1 ?. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT +r.r ii # n rr G R 7 <br />LU:.•"d REQUIREMENT <br /> SAMPLE <br />-- C, 7 '?:. =1 MEASUREMENT <br /> PERMIT <br />F, - - •: =; `? t: t, REQUIREMENT <br /> SAMPLE <br />e t= ° • MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />T, MEASUREMENT <br /> PERMIT <br />i" REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />t: REQUIREMENT <br /> SAMPLE <br />:,- MEASUREMENT <br /> PERMIT i:JRT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crtiit: under penalr; ul low that this Jiwumem and all an.uchoients were <br /> <br />d <br />d <br />e <br />TELEPHONE <br />DATE <br /> ance with a system <br />prgw <br />d under my direction or supervuam in accor <br />esigned <br />. <br />r to assure that yuahfict! penonncl properly gather and evaluate the mfinmtaln-n <br />• , . ? <br />)?C< submitted Hosed on tm inquiry of the person or perscm, who manage the system. <br />? <br />- or those persons directly responsible for gathenng the infbrmauon. the information ??" - ? ` " <br />•?'=? <br />L i submutA is. to the heat of my knowledge and bceef, true. ac orate, and complete. <br />f <br />I <br />th <br />t th <br />i <br />f <br />t <br />fti <br />f <br />b <br />i <br />k <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />PRINTED <br />O orma <br />am aware <br />a <br />ere are s <br />gni <br />ican <br />pcna <br />es <br />or su <br />mitt <br />ng <br />a <br />e <br />n <br />on. <br />i <br />ihd <br />f fi <br />k <br />d <br />i <br />f <br />l OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED <br />R m lu <br />mg r <br />te poss <br />try o <br />imprisonment <br />m wmg s ro <br />ne ant <br />or <br />anc't's CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3,199) Previous editions may be used. ,?31 ,- This i5 a 4-Part form.