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PERMITTEE NAME'ADDRESS rlncludeFacilin Vame.4,on•arion ijlhjjemno <br />NAME I, <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 />Y . <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT >: x F <br />c! <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/T1TL.E PRINCIPAL EXECUTIVE OFFICER I ecrttf} under penaltc,t lays that this document and all attachments were TELEPHONE DATE <br /> prepaml under my dirwiwi or super rsion in acco dunce with a ssswni designed <br /> to assure that qualified rarnonncl properly gather and eealuatn the information <br /> submtnd. Based on my inquirs' of the person or persons who rnatrace Ore .}stem. <br /> or those persons directly responsible Gx gathenng the mformanon, the inforrnatinn <br /> to the best of my knouiedgc and beliel trae <br />accurate <br />and cntnp1cw <br />suhntined is - <br /> . <br />. <br />. <br />!t1 <br />!a -h <br />imn <br />1AI„ mn,rr,:ae1,n <br />th <br />!': <br />'! <br />I <br />t th <br />' <br />h SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />I am auare <br />em arc siL <br />l.1 <br />14 <br />:i <br />2 <br />m <br />g <br />- <br />a <br />nt <br />f f OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PR <br />NTED including the p rs;ihdity o <br />ine CODE <br />COMMENTS AND EXPLANAI IUN Ut- ANY VIUL.AI IUN, (Hererence an arracnments nere) <br />-IR RE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. Th13 13 A 1-part form.