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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDifferent) i <br />NAME <br />ADDRESS s _ <br />FACILITY <br />LOCATION,' <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. ` <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040 0004 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD - - , <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br /> ..... ? ......................... - wu .r..1 ..y In a .V1I1. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br /> EX TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE :- <br />:", -;%:'•. '.'.;' . _ MEASUREMENT <br /> PERMIT ._..: t <br />_ : ,...• . REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />. <br />r <br /> <br />, REQUIREMENT <br />:. SAMPLE <br /> MEASUREMENT <br /> t <br /> PERMIT . <br />xifl i.., . t <br />l;. t <br />..; F tY .. + ?? <br />I ' REQUIREMENT <br /> SAMPLE ; <br /> MEASUREMENT <br /> <br /> PERMIT _J_ <br /> REQUIREMENT <br /> SAMPLE <br />``- <- MEASUREMENT <br /> ;. - . <br /> PERMIT , <br />, t s> <br /> <br />r-;• .. --?, .. _ ,. . <br />. .-: - . <br />-_ .., <br />. <br />. <br />..} ' : REQUIREMENT .. r +.,. .. <br />MLHATfl <br /> SAMPLE ,_. <br />l-" MEASUREMENT <br /> z• ; <br />x ;; . <. <br />. <br />t <br /> PERMIT • . <br />;; <br />? : ?. 3 rt Z; 01-1 [ 1 <br /> REQUIREMENT '; <br /> SAMPLE <br /> MEASUREMENT <br /> _ :.,.. <br /> PERMIT <br />t REQUIREMENT k <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were T ELEPHON E DA TE <br />.. prepared under my direction or supervision in accordance with a system designed <br />r y,\ ! ?`•- t\ f ,j? 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, <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 EXECUTIV <br />TY 1 aware that there are significant penalties for submitting false information, ? <br /> <br />PED OR PRINTED <br />including the possibility of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED A <br />GEI?T AREA <br />NUMBER <br />YEAR <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOI <br />.ATlnluc iaofe.o.,, a -u ?ff?,.?,.s...? ti--% CODE MO DAY <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />J ^_ _ ;Tliis;is`a 4'pait:form. PACE OF