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PERMITTEE NAME/ADDRESS (Include Facility Name/LocationifDierent) <br />NAME _ i <br />ADDRESS I <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 />DAY <br />TO <br />Form Approved. V <br />OMB No. 2040-0004 ; <br />a <br />T 5zn <br />NOTE: Read Instructions before comDletina this form. <br />PARAMETER <br />. QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUEN Cr AMPLE <br />? EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS „?.. - <br /> SAMPLE ; <br />T'' MEASUREMENT <br /> PERMIT ;,'i,_: <br />r: ' '.-•` REQUIREMENT <br /> SAMPLE r i .: . <br /> MEASUREMENT <br />.. <br />- <br />PERMIT <br />7 yr <br />-c ii. r a. <br />r <br />I x s m <br />T 3 <br />r° <br />td i`- <br /> REQUIREMENT 7 L 'Y' M X I t0; <br /> SAMPLE <br /> MEASUREMENT <br /> <br />i . . <br />PERMIT <br />7777 ?> <br />? <br /> <br />t'. <br />a.: <br /> <br />A7 7 _f <br />71 <br />r r Y a.t REQUIREMENT I"S.-:"fT i <br />i SAMPLE <br /> MEASUREMENT <br />i._ PERMIT <br />E F s REQUIREMENT A A, 1)A T ? !"ic y ht`# <br />'-` SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />F7F REQUIREMENT M f tC;If?i Te ; <br /> SAMPLE 1 ;...; <br /> MEASUREMENT <br /> <br />.? <br />PERMIT is tt . <br />.. <br />n <br />EF ` i..; I F7 REQUIREMENT IIf'Jr, <br /> SAMPLE <br />TUT •r .>.... .. F , :,.' ; '-. MEASUREMENT <br /> PERMIT <br />EF' )_,_:. REQUIREMENT `'` <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br /> <br />.•''' " - j: - <br />; <br />; prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the information <br />: <br />1 ,1 <br />1 <br />j <br />q <br />` <br /> <br />- <br /> submitted. Based on my inquiry of the person or persons who manage the system, --? <br /> or those persons directly responsible for gathering the information, the information <br /> submitted is <br />to the best of my knowledge and belief <br />true <br />accurate <br />and complete 1_ ' i l t t <br /> , <br />, <br />, <br />, <br />. <br />I <br />th <br />t th <br />ifi <br />t <br />i <br />l <br />i <br />f <br />b <br />it <br />i <br />f <br />l <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE C. <br /> <br />TYPED OR PRINTED am aware <br />ere are s <br />can <br />pena <br />a <br />gn <br />t <br />es <br />or su <br />m <br />t <br />ng <br />a <br />se <br />n <br />ormat <br />on, <br />including the <br />ossibilit <br />of fine and im <br />risonment for knowin <br />violations OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> p <br />y <br />p <br />g <br />. CODE <br />%,vrvnnorvt, Hiw CArL +IIJAIww yr rAwl vwLNlIVIMQ 11101l.'rC17Gtl au allaGnmenW nere/ <br />i <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. (: '; )Ct-J-' ;' ?` ;?'W9154t 4 0C ft-fo1'm. PAGE ?? OF