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PERMITTEE NAME/ADDRESS (Include Facility Nante/Location if Different) <br />NAME - <br />ADDRESS .- <br />FACILITY <br />LOCATION ,i <br />Form Approved. r <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER { <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY OF SAMPLE <br /> EX TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />t r ,, • SAMPLE - "' . -.._ .:§^...:, .: •w r....t--,?: <br />r t+ ; i °t; MEASUREMENT <br />+ PERMIT ? .. . _ a. _, . , r _, .. ' ...? . r _ ... ,'.. _.{ , <br />£. REQUIREMENT t <br /> <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 certify under penalty of law that this document and all attachments were TELEPHONE DATE <br /> <br />?- prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the information <br />y {'g•?d?r.,? 1 l? s? -r submitted. Based on my inquiry of the person or persons who manage the system, <br />-.? <br /> or those persons directly responsible for gathering the information, the information <br /> submitted is, to the best of my knowledge and belief, true, accurate, and complete. `- <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />i <br />u <br />- ?' <br />`•' <br />-•• <br />' 1 am aware that there are significant penalties for submitting false information, I <br />GENT <br />C AREA <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFI <br />ER OR AUTHQR <br />ZED A <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Heterencre'' all atracnmenrs nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br /> <br />11 S.:t$r a A E Cr f©rm. PAGE ,., OF <br />fJ