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PERMITTEENAMEIADDRESS IrrClLl/CFncllin.4'umNltxofinni/Difjerrnu <br />NAME <br />ADDRESS <br />- <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 />i <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 /> REQUIREMENT f . <br /> SAMPLE <br /> MEASUREMENT' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />,;•;. _ MEASUREMENT <br /> PERMIT # - d •. i :1?. T <br />- REQUIREMENT i t ;11 X <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT d h c :- <br />:= r REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- r REQUIREMENT <br /> SAMPLE <br />-r „ RA13L_H MEASUREMENT <br /> PERMIT ,-- r, c' -T {? F,cR l <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cenify under penalty of law that this document and nil attachments were TELEPHONE DATE <br /> prepared under my direcfnn or supcn-ismn to accordance %nh a system designed <br />' ?i ?• = to assure that qualified persnnnel ptoperfy gather and c%alwac the information _ _ -?- . - <br /> submitted Based on my inquire of the person or persons who manage the system, .= <br /> or thvse persons directly resp.msible for gathering the information. the inf ormation <br /> <br />' suhmni•d is, to the best of my knowledge and hc•hcf. trvc. accurme• and c••mploc SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there arc significant penalties to! d,oimng false iniorrav•n. <br />mcludrn¢ the p ssibihn of firer. arai impnsonmem f r krowmg minti m OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />CONIF41ENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3.!99) Previous editions may be used. -) _ tat This is a apart fonn.