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PERMITTEE NAMElADDRESS,include Frrdir. ',.:•r:. i....r1 j)jjt .,, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />NOTF Raari Inctrlrl^tinnc hnfnro <br />Form Approved. <br />OMB No. 2040.0004 <br />thic fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />> <br />< OF <br />TYPE <br /> - AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r <br /> REQUIREMENT <br /> <br /> SAMPLE <br />T <br /> MEASUREMEN <br /> PERMIT <br />;r al REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT z ly CI <br /> REQUIREMENT .: r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t...r. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r.- . r :..... <br />F REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT rv t: m <br /> REQUIREMENT <br />NAMETITLE PRINCIPAL EXECUTIVE OFFICER I ecntt} under penalty tit law that this dU:nmem and all ati,uhtnent% were TELEPHONE DATE <br /> prepared under my direction or supemson in accordance with a system designed <br /> <br /> <br />?` - to assure that yqnlhfied - <br />personnel properly gather and evaluate the inf.?mmtnuon <br />_-- <br /> submttcd Based on my mqutrs of the person or persons who manage the --sysurm. <br /> of those persons d tcof5 re>ponarbfe for gathering the Intor oration. the information <br />- ubmitlcd 15, to the be-t of my knowledge and hchef. true. ace umtc, and complete <br />I <br />Th <br />h <br />i SIGNATURE OF PRINCIPAL EXECUTIVE n <br /> Im aware <br />at t <br />ere arc signif <br />cant penalties tnr subnutung false information <br />TYPED OR PRINTED it;udtl e the ponsibihty of fine and imprisonment I'm knowme violations OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />f1fNIL SAChiT0 AMM CVnl AAIATI/lkl e%r AMV \11^1 ATIA?Il^ ln_t______ _ _ <br />01I O{{ac II IICrI{.i ere/ <br />EPA Form 3320-1 (Rev. 3,199) Previous editions may be used. 1 4 3 , is is a 4-part form.