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PERMITTEE NAME/ADDRESS,! m h,,!, 1 ,n :;:r rru, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <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 r 7 i <br />( REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ? T I-POF?T RL `• <br />1 REQUIREMENT .' <br /> SAMPLE <br />7; - 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 cr[ifi under penalty of law that this J:RUment and all auachmcrus wcr TELEPHONE DATE <br /> <br />- prepared under my direction or supenisiun to accordance with a system destened <br />. <br />- - <br />T <br />•?? • - ' ?` d gather and ecahmte the information <br />to assure that qualified prrmnncl pmperk <br />submitted Based on my inquiry of the person or perums who manage the system. - <br />- ' - <br /> or those persons directly respumibde for gatlxnnc the mforttwum. the mfom,ation <br />_ <br />` <br />' submitted is, to the best of my In wled¢ and bell t: true a urns and ,,mploc <br />n , <br />r <br />h <br />t <br />i <br />ih <br />i <br />t <br />t <br />1 <br />h <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br />-~ <br /> n <br />xn <br />_ -.t <br />rni <br />. i <br />vsa tr <br />. r u <br />am aware t <br />at t <br />ere are c <br />gn <br />rt <br />1 OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />Y <br />TYPED OR PRINTED + ,,,. r.: <br />itwludn4 the pnstbil+ty of fm , unpr , nn ,t fi•i CODE DA <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3;'99) Previous editiors may be used. This is H-part fDf1T1.