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PERMITTEE NAME/ADDRESS ,Include Fucihv '-,,.. . mfjerrnel NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY <br />YEAR MO DAY YEAR MO DAY <br />LOCATION 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 /> MEASUREMENT <br /> PERMIT <br />T <br />???:::• <br />t REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , F' is ii <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> r <br /> PERMIT } <br />-r- - REQUIREMENT - <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT j' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br />I' REQUIREMENT " F <br /> SAMPLE <br />L ; z ,. •? MEASUREMENT <br /> PERMIT . ?. ;. >. <br />j; REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> t :r 7T <br />- cFt, Ir r <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ;coif under penalty of law that this dcwument and Al anachnnmts were TELEPHONE DATE <br /> ared under my direction or supervision m accordance with a sysum de- igned <br />re <br /> p <br />p <br />u, assure that qualified personnel properly gather and eculuate the information <br /> <br />- submuted Baud on ms inquiry of the pe.rson or cracros who mart gc the system. <br />the information <br />cm+tble for gathenng the information <br />ersons directl <br />res <br />o <br />tho - - <br /> . <br />p <br />se p <br />y <br />r <br />submitted is, to the hest of my knswledge and belief, tom. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ' <br /> i am aware that there arc significant penalties for submitting false Information. OFFICER OR AUTHORIZED AGENT AREA <br /> ot for knawme ciolanons <br />d <br />nm <br />ibili <br />f f <br />l <br />d <br />h CODE NUMBER YEAR MO DAY <br />TYPED OR PRINTED ine an <br />impr w <br />e <br />ing t <br />e poss <br />ty o <br />inc <br />u <br />COMMLN IS ANU LAFL.ANAI IUN Ur ANT vlULJAI vrva <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.