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PERMITTEE NAME/ADDRESS,Include Fa ilin 5amm'L wwian ?fDgerrnrr <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 />Form Approved. <br />OMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. Of FREQUENCY SAMPLE <br /> >< EX TYPE <br /> ANALYSIS <br /> I AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT „ • {r a ,: r <br />w REQUIREMENT ?. -- <br /> SAMPLE <br />r.r MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT R A?< <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />i REQUIREMENT f ! ?,'t ; t .-: r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT s: •- - .. QR T REPORT i -. . . <br /> REQUIREMENT tat.''-> Grp i t_-Y• 161 <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under pcnalty of law that this document and all attachnuenfs weft, TELEPHONE DATE <br /> prepare.] under ms dues-rtm or supcn uion in accordance with a syste+n designtM <br /> to assure that qualified personnel properly gather mid evaluate the infomatwm <br />submitted. Based on my inquiry of the pemm or persons %Iw manage the system. <br />_ <br /> or those persons directly respkmsublc I'm gathering the information, the mformalwn - <br />.. accurat <br />and com <br />lcty <br />t <br />d h <br />f <br />tr <br />e <br />d i <br />b <br />f <br />k <br />l <br />d <br />h <br />h <br /> now <br />. <br />u <br />, <br />e, <br />p <br />+vbmitte <br />s, to t <br />e <br />es <br />o <br />my <br />e <br />ge an <br />e <br />e <br />f <br />b <br />fal <br />i <br />i <br />o <br />i <br />o <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br />J <br /> tting <br />se inf <br />rmat <br />on, <br />I am aware that there are sfgnn <br />cant perta <br />t <br />cs f <br />r su <br />m <br />t f <br />k <br />i <br />v <br />l <br />h <br />(f <br />d OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPED OR PRINTED now <br />or <br />ng <br />io <br />ations <br />including thr pxsihi <br />n o <br />inc .m <br />imprisonmen CODE <br />CUMMtN IS ANU tXF'LANAI IUN Ur ANY VIULAI IUNJ (He?erence au actacnmenrs rrnrrl <br />PREC IP - EVEN i' - 5EE 1. A. I. , PG. 3 FOP f? EMENTS. <br />MPL I N,:: I INS7i;'.UC T IONS - T ? , P- 14. <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a _4-part form.