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PERMITTEE NAMEiADDRESS ilneGcclr F.ihn Fame'z"aawt iJ Dfiferent) <br />NAME <br />ADDRESS <br />PACILlr( <br />; OCATION <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 /> <br />VOTE: 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 /> 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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccrufy under penalty of lain that this document and all anachments wcn TELEPHONE DATE <br /> prepared under m.N d,recuon or supen iston to aw,rdancc w tth a system designed <br />--- to assure that qualified personnel properly gather and evaluate the information <br />Based on m} mqutn of the person or persons who manage the system <br />submitted <br /> <br />- . <br />. <br />or those persons do ctly mpimsihle for gathering the information. the information <br />l <br /> <br />submitted is. I. the he.z of my knowledge and halief. true, accurate. and complete <br />i <br />l <br />i <br />I <br />h <br />h <br />f <br />f <br />b <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />d <br /> <br />D <c :w-nannn- <br />en arc s <br />icant pena <br />am aware t <br />at t <br />gni <br />ncs <br />or su <br />milling tn <br />L u <br />h <br />f <br />i <br />d i <br />f <br />k <br />l <br />i <br />h <br />h OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTE or <br />. <br />i <br />n o <br />t <br />ne an <br />mpnsontncnt <br />nown <br />mc <br />ud <br />ag t <br />e poUt CODE <br />GOMMENIS ANU tXPLANAI IUN Ut- ANY VIULAIIUNJ (nererence an arracnmenrs nere) <br />This EPA Form 3320.1 (Rev. 3,199) Previous editions may be used. ls,a ?-pdM tOrnL