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PERMIT-TEE NAME/ADDRESS Na.1„d, h- . .,,,. <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 />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 />i ;L;,- MEASUREMENT <br /> PERMIT <br />-1 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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all amichmenr wee TELEPHONE DATE <br /> prepared under mm direction or supervision in accordance with a system designed <br /> to assure that qualified personnel properly gather and e.aluate the information - - <br /> submitted Based on my inquiry of the person or patio, who numage the seems n - <br /> or those persons directly mponsible for gathering the information. the <br />_ submitted is, to the best of m% knowledge and belief. true. mcuraw. and complete <br />b <br />l <br />f <br />t <br />f <br />f SIGNATURE OF PRINCIPAL EXECUTIVE < <br /> <br />PR <br />D orma <br />ion. <br />or su <br />nunme <br />se in <br />I am aware that there arc signo,aw penalties <br />a <br />m tnr k <br />snmlations <br />! <br />wm <br />w-in <br />h <br />f ti <br />l <br />d <br />b <br />li OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR <br />INTE . <br />n .m. <br />unpn <br />nme <br />no <br />g <br />ing t <br />ty o <br />inc <br />u <br />e possi <br />i CODE <br />COMMENTS AND EXPLANAIIUN Ur ANY v1ULAIIuNJ (nererence au anacnmerim here) <br />PRECIP EVE,-NI - EEF _ A. 1. PG. 3 FOR RF.t?f?IF.1 rIENTS: <br />+ i L I NG Z N5l'R VC T I ONS - i.. C 7. F= 14. <br />EPA Form 3320-I (Rev. 3199) Previous editions may be used. "016e This is it 4-Nrt font].