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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME
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<br />FACILITY
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<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT (DMR) ii i, f cs
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<br />PERMIT NUcMBER DISCHARGE NUMBER
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<br />MONITORING PERIOD
<br />YEAR MO DAY T^ YEAR MO. DAY.
<br />FROIVI I :. I :. I I v
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER
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<br />< QUANTITY OR LOADING QUALITY OR CONCENTRATION NO,
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<br />EX FREQUENCY
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<br />TYPE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE. MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were
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<br />d TELEPHON E DATE
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<br />to the best or my knowledge and belief
<br />true
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED on,
<br />1 am aware that there are significant penalties for submitting false informat
<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
<br />CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATIVN OF ANY VIULAIIUN, (rfererence all arracnmenrs nere)
<br />EPA Form 3320-t (Rev. 3/99) Previous editions may be used. 00,-Y,--A ='CWKN',OA 4-Nif4Orm. PAGE ?OF
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