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PERMITTEE NAME/ADDRESS ,h,,1-J, l;a; hn '-m: <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 />Min <br />( 51- <br />F - <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION , OF <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a: r W T C E i ' T !!IUA <br /> REQUIREMENT MONTH <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 EXECUTIVE OFFICER I certify under penalty of la, that this document and all :machment. w rc TELEPHONE DATE <br /> prepared under my direction or supen won in accordance wnh a systern designed <br />l f- ' r+ to assure that qualified personml properly gather and e% aluate the information <br /> submitted Baud on my mgwry of the person or persons wfin rttanage the system, - <br /> or those pcmons directly responsible fur gathenng the informatnm, the mtimnatiim <br /> wbm,ttcd,s, io the best of my knowledge and belief". true, accurate, and complehe_ SIGNATURE OF PRINCIPAL EXECUTIVE <br />` lties for submittin <br />false information <br />a <br />r <br />i <br />nificant <br />en <br />I <br /> <br />D <br />R <br />I <br />T mn <br />e s <br />g <br />p <br />a <br />g <br />. <br />a <br />d i <br />l <br />f f <br />f <br />k <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED O <br />N <br />E <br />PR mpn mmem <br />or <br />now <br />ng s n <br />anon> <br />inc , : b,lny o <br />ine an CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />iR PRE <br />C.GMPI <br /> <br />EPA Form 3320-1 (Rev. 3;99) Previous editions may oe used. This is a 4-part fomi.