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PERMITTEE NAME/ADDRESS
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<br />Form Approved. i
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER 4"..
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 7 TO s
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were TELEPHONE DATE
<br /> prepared under my direction or supervision in accordance with a system designed
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<br />•n•°"FSIGNAT RE OF PRINCIPAL EXECUTIVE ,
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<br />/? 1 am aware that there are significant penalties for submitting false information,
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<br /> risonment for knowing violations.
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all arriacpynmenrs nere/
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<br />PAGE
<br />OF
<br />4-p tjgn 1.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. - ` : ; -
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