Laserfiche WebLink
NAME <br />ADDRESS <br />(Include Facilirv Vame Location JlWfemnry <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION sVSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MID 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 /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 cenify under penalty of law that thu ddwument and all attachments were TELEPHONE DATE <br />prepared under my direction or super Won in accordance with a system designed <br />l- - tc: assure that qualified personnel property gather and evaluate the miortnation <br />rson or <br />erson, who manage the system <br />>? <br />' ;? ?' <br />f the <br />h <br />itt <br />i B <br />d <br />- <br />! , • <br />pe <br />p <br />su <br />m <br />ct <br />ase <br />on my mgwn o <br />the information <br />responsible Ibr gathering the information <br />or Iho <br />e <br />ersons directl <br />'? -y - <br />. <br />y <br />s <br />p <br />?- submitted is. to the hest of my knowledge and belief. tnie, accurate, and complete <br />I^ SIGNATURE OF PRINCIPAL EXECUTIVE <br />I am aware that thee, are- ,igniticant penalues for submitting false mfonnatwn. <br />n <br />i <br />k <br />l <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR MO - <br />DAY <br />nns <br />er <br />nowtnB vo <br />a <br />TYPED OR PRINTED including the pa hiht, of tine and imprisonment t <br />ss CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLAI IUNS (He?erence an anacnments nerej <br />HR PREC IP. EVENT - SEE I. A 1. , PG 3 FOR R`=,W-!T ?-tEr <br />SAMPLING JNSTS't)CTIONS - I C. 7 t P-G 1.1. <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. F This is a 4-part, fonn.