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PERMITTEE NAME/ADDRESS (Include Facility NamelLocation If Different) <br />__ .. ._ a . l , . <br />NAME <br />ADDRESS t <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 />Form Approved. i <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER t QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />P <br /> ANALYSIS TY <br />E <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />' SAMPLE -. .... ? ,:, .,.; ,/^x' - •-. ; ...:; . ;. ;.,.;..- ? : <br />A <br />I °.. <br />. MEASUREMENT <br />!'.`sC PERMIT <br /> <br />, . ,. <br />r, I <br /> <br />z E_ <br />REQUIREMENT; 1 J-' <br /> SAMPLE <br />r <br /> MEASUREMENT <br />•v- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE ,I <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT' <br /> SAMPLE t' 4 <br /> MEASUREMENT <br /> PERMIT ti <br /> REQUIREMENT: <br /> SAMPLE + <br /> MEASUREMENT ; <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />d <br />d <br />e <br />d <br />TELEPHON <br />E <br />DATE <br />` ( D <br />p <br />-PA E D F <br />K prepare <br />un <br />er my dir <br />ction or supervision in accordance with a system designe <br />to assure that qualified personnel properly gather and evaluate the information <br />ri <br />t <br />& <br />submitted. Based on my inquiry of the person or persons who manage the system, A <br />V t <br />l <br />M <br />5 or those persons directly responsible for gathering the information, the information <br />F <br />Y <br />. <br />G G" <br />) T <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />j <br />47 <br />? <br /> <br />1 am aware that there are significant penalties for submitting false information IGNATURE OF PRINCIP IE E ECUTIVE V <br />1 l ?. <br /> <br />TYPED OR PRINTED , <br />including the possibility of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT AREA <br /> <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />VVIYIIWIG III IQ NINW GAr G111?M I IVIN Vr- MINI II IVLNI IVIVQ (nCICIC114r [III flllaulli1/turlib 11crul <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br /> <br /> <br />Qta i. Cfhi516;d #-bgtwrm. PAGE ZOF