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r <br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDierent) <br />NAME <br />ADDRESS i :. <br />FACILITY <br />LOCATION • a _ . '.. " i „` . .._ <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) {`l OR <br />PERMIT NUMBER DISCHARGE NUMBER <br />50HO T(3 1-01 <br />MONITORING PERIOD f' <br />YEAR MO DAY YEAR MO, DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. - <br /> NO FREQUENCY SAMPLE <br /> QUANT ITY OR LOADING Q UALITY OR CONCE NTRATION . <br />X OF <br />TYPE <br />PARAMETER E ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />t <br /> SAMPLE <br /> <br />I . : I , MEASUREMENT <br /> <br />7 <br />r <br /> <br />t? t J <br />31(> _ ; ,:; PERMIT ari ;## r xy <br />, <br />r x <br />' <br />iGr <br /> <br /> <br />C11?1TF? <br />1..t!c <br />EF <br />_.. ? REQUIREMENT <br />f <br />r.? ?• <br />? •4 : t >s, <br />_ SAMPLE ?-?1• <br />;; . •? :, , <br />. <br />. <br />f J r l, <br />, MEASUREMENT <br />' <br />• <br />t' <br />t?4ta .. t <br />L1..7 <br /> <br />PERMIT <br />?x ;: r:..;k <br />9E a ?i <br /> <br />t <br />F <br />HE <br /> <br />°i' <br /> <br />MONTH <br /> REQUIREMENT <br /> <br />r <br />z <br />, <br />r r <br />i <br />77 1.7F <br />! .. . - SAMPLE r x <br />a . Y: <br /> <br />t ;) MEASUREMENT . t t +t : t t, _, <br />t - <br /> <br />PERMIT 3r n '- 7 L , <br />'I L_?{ <br />IV, C ' t _ <br /> <br />-I^'i <br />I1IDN <br /> <br />? <br />F REQUIREMENT <br /> <br />I SAMPLE <br /> <br />T01-6L. d F- MEASUREMENT e i <br /> <br /> <br />j <br /> <br />PERMIT <br />;f X <br /> <br />_ <br />'U"', MONTH <br /> REQUIREMENT <br /> y r ( s <br /> SAMPLE ' <br />" <br />" <br />' <br />= <br />ry <br />'' _ <br />>= <br />' ? MEASUREMENT <br />.. <br />'.? J.. PERMIT <br />'rE' # .1. N...7..;?. <br />•'?• . fi :S .rl ..r ? <br />i4' •# <br /> <br />.. <br />.tt, .. <br />t t <br />"• <br />L, <br />f?Y \V V <br />(?. <br />.. <br />(?/ <br />T IyiK <br />r t-1II <br /> <br />1 r , L. <br /> <br /> <br />IIN 11 7 <br />r•• 1 T .. t•'{,: C`Y <br />/..t 1 <br />t•r <br />_ REQUIREMENT ' • n. n [ <br />1 <br />,., <br />I .._ <br />+?4 <br />. „ <br />_ <br />.. <br />' <br />" <br />•f"'?Y -i?-'.i -r.. i. <br /> <br />l I <br />. r10 <br /> <br />... <br />SAMPLE <br />.. 47 ..: ... <br />'1} <br />,.Y'#'? <br />:, <br />.1. <br /> r <br />eggt.f MEASUREMENT r <br />1 PERMIT <br />rnIE 'Y` ' i•z <br />t '?.. <br />MONTH <br />4 REQUIREMENT <br /> <br /> # ,.y <br /> SAMPLE <br /> <br />r <br />TI~1T,t- <br />MEASUREMENT <br /> PERMIT <br /> <br />., 4,, # ~ <br /> <br /> <br />A r L -Y MX <br /> <br /> <br />C ' l- Mdd'T <br />H <br />t <br />L <br />t:?r'?f <br />OF REQUIREMENT _ <br />. TELEPHO NE D ATE <br /> th <br />t <br />f l <br />l this document and all attachments were <br />NAMINCIPAL EXECUTIVE OFFICER I certif <br />ar <br />re aw <br />a <br />y under pena <br />ty o <br />ed under my direction or su pervision in accordance with a system desig ned .-? <br />` <br />z p!! <br />` <br />,? <br />t p <br />p <br />to assu re that qualified personnel properly gather and evaluate the information <br />• 1 I l? •IJ <br />f n. <br />? submit ted. Based on my inquiry o f the person or persons who manage the syst <br />f <br />h <br />i <br />i em, <br />tion <br /> or thos e persons directly res ponsib orm <br />on, t <br />e <br />n <br />le for gathering the informat a 1?;,? <br /> b <br />it to the best of my kn <br />ted is owledge and belief, true, accurate, and comp lete. $IGNA TURE OF PRINCIPAL EXECUTIV <br />Ti7 m <br />su , <br />ifica <br />i <br />h <br />h enalties for submitting false information <br />nt , OR AUTHORIZ ED AGENT ARE A <br />YEAR <br />MO <br />DAY <br />b TYPED OR PRINTED I am a <br />includ gn <br />ere are s <br />at t <br />ware t <br />ing the possibility of fine an p <br />d imprisonment for knowing violations. OFF ICER COD E NUMB ER <br />i <br />I'' COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />L <br />PAGE ? OF? <br />d <br />. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be use <br />