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PERMITTEE NAME.rADDRESS rhoclude Fucd r) Vwn,• 1. watwn rfDifjennt) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />t, -A A U <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 />NOTE: Read Instructions before comDletinq 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 W •' - <br />1 REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r1 ;: rl <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT r: tr p : f.• C' tt.t <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TM-E PRINCIPAL EXECUTIVE OFFICER I certif, under penalty of lavs that Iris d.>LUntent and all attachments wire TELEPHONE DATE <br />_ prepared under my direction or supervision in ucurdance with a system designed <br />r <br />• <br />-- to assure that quatifi d personnel prmperi) gather and evaluate the nfomtatnm _ <br />• <br />, <br />z submitted- Rased on my inquiry of me person or persons whn manage the system. <br />? <br />- ?? <br /> ,ible tier gathering the information. the mfortnatitm <br />ersons directly respur> <br />or those '? <br /> _ <br />p <br />submnrd is, to the best of my knowledge and belief, true. actnratC, and completc- <br />SIGNATURE OF PRINCIPAL EXECUTIVE . <br /> I am aware that there are significant penalties for suhnunmg falsc information. <br />l <br />i <br />k OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED wAine , io <br />an.vr <br />r <br />including the lx?ssibility of tine and Imprisonment a CODE <br />COMMENTS ANC LXNLANAI IUN OF ANT VIULAI IUIYJ trrererence du auacr nnvrrra „cr ct <br />°kECIP. i~VEl,!T - l_K i. A. 1, RG 3 FOR REGJI19,7P1ENTO. <br />3r' MPL I NG 't•;' ' HUC I [ OP•ES - I - C 7 , F'.?. 1'Y <br />EPA Form 3320-1 (Rev. 3!99) Previous ed'Riom may be used This is a 4-part form.