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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />, <br />ADDRESS :' <br />FACILITY <br />LOCATION ..' <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO . <br /> <br />Form Approved <br />OMB No. 2040-0004 .4 <br />r :, . . <br />P, <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQIJ NCY, SAMPLE <br /> EX T <br />PE <br /> ANALYSIS Y <br />- <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />71,t t T t` '" SAMPLE <br /> MEASUREMENT <br /> PERMIT _• ::. a !¢ c <br />E °T ; . r--f t t_ ,.. 1 REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />3 PERMIT I .< ?o .? ? , . t- r< :i--?• ? ? REP, <br />..ag'•I3 - _ REQUIREMENT <br />„ . SAMPLE <br />-T:'µ MEASUREMENT <br />{ PERMIT ' <br /> REQUIREMENT , . <br />;., SAMPLE <br /> MEASUREMENT <br /> PERMIT h , <br /> REQUIREMENT t }e\ <br /> SAMPLE ,.i .. <br />TI..{ ?9 ? {'. i' ""•;'i" , MEASUREMENT <br /> PERMIT "- 5 <br />m . S i 1 <br />he t,' <br />r"4. 1 ?, x , . <. <br />Fr' REQUIREMENT <br /> <br />,, l- ,x <br /> <br /> <br />: 'r.) <br /> <br /> <br />«'..?..n, .r?. <br />av_ <br /> <br />S.3 t•. <br /> SAMPLE <br />c}:a"? ',.? i= ? MEASUREMENT <br /> PERMIT E T' ;• .1{ a# 3E ?r r: ..r_ p : .,i b_ ?[ t s <.. ';? <br />r... S : iiNa s 777 <br />_ <br />F'. i_.t;i_ REQUIREMENT .E <br /> SAMPLE ,- <br />s t MEASUREMENT <br /> <br /> <br />'` <br />PERMIT <br />? <br /> <br />Id <br />m <br />' t": f ,--s,' REQUIREMENT <br />r <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty orlaw that this document and all attachments were <br />d <br />d <br />di <br />ti <br />i <br />i <br />i <br />d <br />i <br />h <br />d <br />i <br />d ` TELEPHONE DATE <br /> prepare <br />un <br />er my <br />rec <br />on or superv <br />s <br />on <br />n accor <br />ance w <br />t <br />a system <br />es <br />gne <br />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 /> <br />I'_-.? <br /> or those persons directly responsible for gathering the information, the information ?. <br /> submitted <br />is, to <br />the <br />best o <br />of my know <br />ledge and <br />belief, true, <br />accurate, and <br />complete. ! I se /> I t + <br /> I am aware <br />that <br />there <br />are <br />significant <br />enalties for <br />submittin <br />false <br />information SIGNATURE OF PRINCIPAL EXECUTIVE w <br />TYPED OR PRINTED p <br />g <br />, <br />6 the possibility of fine and imprisonment for knowing violations. <br />including OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />r <br />cUMMENT5 ANU EAFLANA I FUN Ur* ANY V FULA I IUNJ (Ffererence all arracnmenrs nere) <br />i <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ,,?}? is a 4Tt fQrYp• PAGE OF ,