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PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO, <br />EX <br />FREQUENCY <br />OF <br />ANALYSIS <br />SAMPLE <br />TYPE <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />1 cert111 under penalh od Ian that this document and all attachments slere <br />prepared under 1111 direction or superision in accordance nith . stem designed <br />to assure that qualified pet cannel pr 1pei IV gather and es actuate t ie information <br />submitted. Rased on nn inquir\ of t 1e person or persons is Ito nu nage the s,) stem, <br />or those persons direct!) responsible 1'or gathering the [nIormatu n, the uafo1 [nation <br />submitted is, to the best of nn Anon edge and 'whet. true aura ate, and complete. <br />I ant aware that there me sigmhcan penalties fo1 submitting lad a information. <br />including the possibihh of tine and imprisonment for knon ing smlations. <br />TELEPHONE <br />DATE <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />AREA CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED <br />PERMITTEE NAME /ADDRESS (Include F(060 Name/Location r/ 1)11/11 /11) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />EPA Form 3320 -1 (Rev 3/99) Previous editions may be used <br />FROM <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER <br />YEAR <br />MO <br />MONITORING PERIOD <br />DAY <br />TO <br />DISCHARGE NUMBER <br />YEAR <br />MO <br />DAY <br />This is a 4 -part form. <br />Form Approved <br />OMB No 2040 -0004 A <br />NOTE: Read Instructions before completing this form. <br />PAGE OF <br />