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PERMITTEE NAME/ADDRESS,/ ns lmh- Faciltn Name Lx-arton yDylenenrl <br />NAME <br />ADDRESS <br />F <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <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 />r <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 /> PERMIT <br /> REQUIREMENT _ <br /> SAMPLE = c; ' <br /> MEASUREMENT <br /> PERMIT '. fi . - t= P "P. t t <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 1 certify under pertauy ,dfaw that tht> d Kument and all .attachment were <br />i <br />d <br />d <br />h <br />i <br />d TELEPHONE DATE <br /> ance w <br />a sestcm des <br />prepared under my <br />irection or,upcrnasmn in acao <br />t <br />gne <br />/'" -? A - •/' to asstuc that qualified personnel properfy gather and ecahutte the mhamauon <br /> submnled. Hated on my inquiry of the person or persons who manage the system. <br /> or thou persons directly responsible for gathcrmg the mliwm.uon, the ntforination - - - <br />_ <br /> submitted is. to the best ?-f my knowledge and Whet true accurate, and complete <br />enalties for submittin <br />t th <br />m ar <br />i <br />nificant <br />fal <br />th <br />w mtormatton <br />I SIGNATURE OF PRINCIPAL EXECUTIVE , <br />I <br /> <br />TYPED OR PRINTED g <br />mn aware <br />e <br />e s <br />p <br />g <br />- <br />a <br />' <br />ncludmg the possibility of tiny and imprisonment for knowing .urlarions. OFFICER OR AUTHORIZED AGENT A <br />AR <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous edifiors may be used. I)GC This is a 4 part form.