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PERMITTEE NAME /ADDRESS (Include Facitily.Name /Location if'Different) <br />NAME — <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER I I DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040 -0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />>< <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 />,USPENDED <br />MEASUREMENT <br />PERMIT <br />r ^,� <br />FR r t <br />REQUIREMENT <br />LE.AHLL: <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />n <br />SS <br />REQUIREMENT <br />w..ow 'Aii+11%U1 I <br />SAMPLE <br />HR,U k.A-('MENT PLAN <br />MEASUREMENT <br />PERMIT <br />0050 € 0 0 <br />t- r-1 t e: y it <br />REQUIREMENT <br />SAMPLE <br />ai i§L <br />MEASUREMENT <br />PERMIT <br />400:6 1 C., <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I eertil\ under penalty ol'law that this document and all attachments were <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 />submitted. Based on my inquiry of the person or persons who manage the system, <br />j <br />P j <br />I <br />TELEPHONE <br />DATE <br />Jill,/� <br />ur Ihuse persons directly responsible far gathering the information, the information <br />sSIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />_ <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />I m, aware that there are significant penalties for submitting false information. <br />neludfng the possibility of fine and imprisonment for knowing violations. <br />`t <br />;� <br />_119A... <br />TYPED OR PRINTED <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />GUMMtN I S ANN) LAF'LANA I JUN UF- ANY VIOLA I IUNS (Hererence au attachments nere) <br />�;� r?...T. -, ' ?i.'= - . >; : ? €._Ii?E I IMIT WrIItJEtJ FUR 1t) -`f tt _r4NP Pf f✓CIP EVEN1" `aUBJE.CT TO BURDEN OF F�2t1rJF REi3UIR i�rEl+tlta i <br />-)NY ADDITIONAL DATA SHALL BE SUPPLIED TO THE DIVISION WITHIN 4S 'HOURS. <br />EPA Form 3320 -1 (Rev. 3/99) Previous editions may be used. 0,r: 7 of-/ jhis is a"4 -Part form. PAGE OF <br />