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PERMITTEE NAME,ADDRESS rfnclude Fii N;m A'.el9 anion i(Different) <br />NAME _ <br />ADDRESS <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 />NOTF- Rpari Incintrtinnc hpfnrp rmmnkptmn thic fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I crufy under penalty of lai that this docurnent and all attachrttcros were TELEPHONE DATE <br /> prepared under my direction Or supen rs,on in accordance with a systern designed , <br /> to as:un_ that qualified personnel property gather and caaka,Itc the mf'rrnauon <br />;ubmincd, tlascd on my inquiry of the person orpcrsoa; who Homage the system. <br />-? v <br />_ or those persons directly rcsponsiMe for gathering the information, the mfrmtaunn ? <br />. - - <br />i tibmmed is. to the best of my kmnsledge and belief. true, accurate, and complete <br />ar <br />th <br />t th <br />s <br />f <br />lt <br />f <br />b <br />nu <br />k <br />f <br />t <br />f _ <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PAINTED r. <br />c <br />a <br />igni <br />ican <br />pena <br />ies <br />or su <br />ng <br />ere are <br />m <br />a <br />e tn <br />onnaunn <br />th <br />' <br />h <br />b <br />lit <br />f f <br />d <br />fo <br />k <br />i OFFICER OR AUTHORIZED AGENT AREA <br /> e possi <br />:I- <br />im <br />ni <br />i <br />y o <br />ine an <br />imprisonment <br />r <br />nnwnie „o <br />:m'ms CODE NUMBER YEAR MO DAY <br />?Vmmcll10111?v Gr{ HI\MIIVII Vr 111\T VIWL.MllVl`{o frialurallut; all A{[tll/II11Cf11D tICICJ <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. : - This is a 4-part form. PAGE OF