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PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different) <br />NAME _• <br />ADDRESS <br />T <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 />. _. a .r: . <br />_ <.. .. _ r r tit <br /> <br /> a NOTE: Read Instructions before-com pleting this form. <br /> PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> <br /> SAMPLE .._... _.•, .:.::, <br /> MEASUREMENT <br /> - ., - PERM <br />T <br /> I <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 0- r <br /> „• REQUIREMENT V <br /> ?- <br /> SAMPLE <br /> =,• ; ';•• , MEASUREMENT <br /> P <br />RMIT <br /> <br /> <br />- E <br /> <br />REQUIREMENT 1- 4. <br />T <br /> <br /> SAMPLE <br /> MEASUREMENT " <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE ...:: t t , . <br /> MEASUREMENT <br /> PERMIT <br /> <br /> _ REQUIREMENT <br /> I: <br /> SAMPLE 7 <br /> . <br />.• <br /> _. <br />.. <br />ri y t. MEASUREMENT <br /> • <br />RMIT <br />P <br /> E <br />, -- <br /> »? REQUIREMENT <br />. <br /> r , T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> ,.. <br /> .a s_'. f ;.... REQUIREMENT <br />* ;4 <br /> NAME/TITLE PRINCIPAL EXECUTIVE O FFICER I certify under penalty of law that thi s document and <br />ll <br />tt <br />h <br /> <br /> <br />' a <br />a <br />ac <br />ments were <br />prepared under my direction or supervision in accordance with a system designed <br />„?•'?•+s T ELEPHONE <br />DA <br />TE <br /> 1 <br />t n <br />Y L. "`•j •,C 1 J?,+ ? <br />6 to assure that qualified personnel properly gather and evaluate the information <br />submitted. Based on my inquir <br />of the <br />er <br />h <br /> ! <br /> <br />? <br />- • <br />•- <br />' y <br />p <br />son or persons w <br />o manage the system, <br />or those persons directly responsible for gathering the information, the information <br />b <br />it <br />d i / <br />? <br /> ?.. <br />. <br />;+.o *: su <br />m <br />te <br />s, to the best of my knowledge and belief, true, accurate, and complete. <br />I <br />C!l <br /> <br />I <br /> <br />' <br />C <br /> <br />TYPED OR PRINTE am aware that there are significant penalties for submitting false information, SIGNATURE OF PRINCIPAL EXECUTIVF Y 4 <br /> D including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT ' <br />' <br /> <br />C <br />OMMENTS AND EXPLANATION OF ANY VIOL <br />ATIONS (Reference all attachments here C <br />ODE NUMBER YEAR MO DAY <br />) <br /> <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />r- _?r_. ,,-,±,1HS.;1S,,4-p3Ct;f91C11. PAGE OF <br />I I ., d