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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME
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<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
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before Uipleting this form.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were
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<br />d TELEPHONE DATE
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<br />prepared under my direction or superv
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<br />to assure that qualified personnel properly gather and evaluate the information
<br />submitted. Based on my inquiry of the person or persons who manage the system,
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<br /> or those persons directly responsible for gathering the information, the information ff
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIG ATURE PRINCIPAL EXECUTIVE
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<br />ED OR PRINTED 1 am aware that there are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing violations.
<br />OFFICER OR AUTHORIZED AGENT
<br />CAREA I ODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />GUMMtN I S ANU hAPLANA I wN Ur AN If V IULA I IUIV.J ft-fererence all arraunmenrs nere/ p ?g t
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used jts-j1 a-4--p t form. PAGE OF
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