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PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />Na <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 />I cerbti under penalt■ of law that this document and all attachments our <br />prepai id under on do ection or sup u"s stun in accordance with : sssfem designed <br />to asset a that qualified personnel pr rper h gather and esaluate the inlormahon <br />submitted. Rased on nn mquu of tie person or persons oho manage the si stein. <br />or those per suns directly responsible for gathering the udormatum, the information <br />submitted is, to the best of nit knowledge and belief. true. auto ale. and complete. <br />I am :mare that there .11e sigudicant penalties Ito S111/1111111104 false information <br />including the possrbdit■ of line and imprisonment for knowing s udations. <br />TELEPHONE <br />DATE <br />r <br />> <br />, <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED <br />PERMITTEE NAME/ADDRESS (Include Fat \anuell.aratiou if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />FROM <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320 -1 (Rev 3/99) Previous editions may be used <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 />NOTE: Read Instructions before completing this form. <br />This is a 4 -part form. <br />Form Approved <br />OMB No 2040 -0004 <br />PAGE OF <br />