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PERMITTEE NAMElADDRESS <br />NAME <br />ADDRESS <br />:.CIL-ITY <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 <br />TO <br />I- L- I <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br />TYP <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS E <br /> SAMPLE <br />_ MEASUREMENT <br /> PERMIT i ". f. <br /> REQUIREMENT <br />- <br />U. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT s<: i <br />J i REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a T' r i? f <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; t -: ,?r• r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , . , in-41 F?-f'(-IPT <br />?L r3L _ REQUIREMENT <br /> SAMPLE <br />P.L F,"-- .:.C` A;JLF MEASUREMENT <br /> PERMIT <br />=S REQUIREMENT ti <br />SAMPLE <br />RL' l .: MEASUREMENT <br />PERMIT i - R *` r' - <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ceritf} undcrpenalty of law that this drxument ;old all attachments Kcr[ TELEPHONE DATE <br /> prepared under my direction or superswon m accordance with a system devgmNi <br />" <br />• <br />- ! W some That qualified peru+nncl properly gather and evaluate the m6o-ma on <br />- auhnnncd- Basad on m} mywry ofthe <br />person or person: Alit, manage the :esiem. <br />- - <br /> or those persons directh responsible for gathering the information, the mfovnation <br /> -hnuncd )s. t„ the best of mp knowledge and belief tnle. accurate, and complete. <br />1 <br />h <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> : n, :rn.:t•: rh,o i <br />,rc arc signif <br />cant penaltxs for suhmining false mirmation, <br />` <br />TYPED OR PRINTED I <br />f nRAAAGAITC Akin CVOI AKIATIfIAI /lC AAIV %Ifni :r.r!.t•Lnr the 1-, hill} of fine and mtpnconmem t„r knnwlr•-g violations. <br />ATIfII.IC /O.. f.. ?........ .. rr ..?..?i??_?_ ?___, OFFICER OR AUTHORIZED AGENT CRONE NUMBER YEAR MO DAY <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. _ T}t1S is a 4-part form.