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PERMITTEE NAME/ADDRESS (Include Fac•rlitr vame.Lawa ion ifDyf emni <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 /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />I REQUIREMENT t t iLli•lTl <br /> SAMPLE <br />t MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ., <br /> SAMPLE <br /> MEASUREMENT <br />I <br /> PERMIT <br />_ REQUIREMENT 1'917! •1 1 ; <br /> SAMPLE <br />r.. MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />= c ?, REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT w.. 1'.."t7F?' {:, T , t'. . <br /> REQUIREMENT <br />NAME,TITLE PRINCIPAL EXECUTIVE OFFICER I r,nir% under penalty of law that this JcKUmem nnJ ail .wa hments were TELEPHONE DATE <br /> prepared under my direction or supervtsron to accordance with a s) -stem designed <br />- -- --/ ?- - <br />?r to assure that qualified personnel pruperl) gather and cv:dwve the mfomtunon _ <br />j <br /> submitted lased on my mqutp of the person or person. who manage the system, <br /> or those persotns directly reapnnmblc for gath«ing the rNbmtation. the ndurtnanon <br /> to the be <br />knowled <br />e and belief <br />we <br />accurate <br />and complete <br />submitted is <br />t <br />f m <br /> , <br />, <br />, <br />. <br />, <br />s <br />o <br />y <br />g <br />t <br />hi <br />tu <br />f <br />u <br />i <br />fi <br />!i <br />h <br />l <br />i <br />f <br />I <br />h <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED can <br />pcna <br />cz <br />,r - <br />rm <br />ng <br />orrna <br />un. <br />wri aware t <br />ere arc s <br />gni <br />a <br />se <br />n <br />at t <br />including the possihrhty of fine ana wqv, n,,;, t t-.r kn-•w ng ciolanon: OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />F R1 <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />This is a 4-part form. PAGE