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PERMIT-TEE NAMEiADDRESSrLr,wd,lr,i:rn. nri <br />NAME <br />ADDRESS <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 <br />Form Approved. <br />OMB No. 2040-0004 <br />i <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = L? <br /> REQUIREMENT '- <br /> SAMPLE <br />=r!R, =; ;_ MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />i t J' •; _ MEASUREMENT <br /> PERMIT <br />c 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 EXECUTIVE OFFICER I certify under penalty of la„ that this document and all attachment. were <br />r <br />d <br />ti <br />r <br />rvi <br />i <br />i <br />ith <br />t <br />i <br />d <br />d <br />d <br />d <br />d TELEPHONE DATE <br /> p <br />epare <br />on o <br />supe <br />on <br />n accor <br />ance w <br />a sys <br />gne <br />un <br />er my <br />irec <br />s <br />cm <br />es <br />- -' - to assure that gtahficd pervmnel properly gather and evaluate the information <br />submined <br />Hased on m <br />in <br />of the <br />erson or <br />cra„rts who mannee the s <br />uir <br />t <br />m <br />.4 q <br />p <br />. <br />y <br />y <br />p <br />ys <br />e <br />. <br /> or those persons dir-ctly responsible for gathering the nrformafion, the mtimnal f, ' - _ - <br />" submined is. to the best of my knowledge and belief: true. accurate, and eompluc <br />I am aware th <br />t there <br />ifi <br />t <br />lti <br />f <br />mi <br />t <br />i <br />h <br />f <br />l <br />fo SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED a <br />arc s <br />gn <br />can <br />pena <br />or su <br />se in <br />rma <br />ion. <br />es <br />m <br />ng <br />a <br />imludmg the possibility of fine and imprisonment for knowing •.,olauons OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> CODES <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. This is a 4-part form.