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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS ..!? .. <br />FACILITY <br />LOCATION <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM? ((NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DAM) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />' <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE - . MAXIMUM UNITS <br /> SAMPLE .::,. .., <br />4? .,.: <br />a? = i. -_ : ? <br />( <br />1)ISIT?{ <br /> MEASUREMENT <br /> PERMIT s <br /> 'REQUIREMENT' <br /> SAMPLE - ... , .. <br /> MEASUREMENT <br />A PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT ,. ,.. .,, •. , -... <br />r. <br />_ REQUIREMENT <br /> <br />SAMPLE 3? ,?5 - /gyp Gt:?B <br /> MEASUREMENT <br /> PERMIT i <br /> REQUIREMENT <br /> SAMPLE <br />10 ? <br />? 22 <br />? 2/3 <br />? <br />G <br />P-AB <br />.... t; MEASUREMENT <br /> PERMIT ,- .. <br /> REQUIREMENT <br /> SAMPLE <br />x <br />23 <br />? <br />3?}2. :. ; : „ .. ... , 3t .. ... . <br />)?? <br />)??ST <br />:, <br />: MEASUREMENT . <br /> PERMIT <br />i..I:. REQUIREMENT <br />c <br /> SAMPLE :.' St r I)? <br />5 <br /> MEASUREMENT V1 <br />U <br />.,..- ._ PERMIT n-? `:•L <br />a` REQUIREMENT < :. . <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br />r <br />?? <br />cS4 <br />Am'- L"'• prepared under my directidn or supervision in accordance with a system designed <br />io 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 />1 <br />` , <br />or those persons directly responsible for gathering the information, the information <br />- - -- - <br />'? ?°? <br />- <br />ti e-y <br />fi <br />3 <br />` <br /> <br /> <br />t t ?? d1-,`? ?Q <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br /> <br />IGNATURE OF PRINCIPAL EXECUTIVE <br />0 ? <br />? <br />'f V B <br />d E) <br />CC•+d. <br /> <br />TYPED OR PRINTED I am aware that there are significant penalties for submitting false information, <br />including the possibility of tine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONb (r?ererence all arracnmenrs nere) <br />n _I <br />r <br />'. O- This 1SI A *.a"r't`f6nn. 10F <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ! w PAGE