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PERMITTEE NAME /ADDRESS lln(Llde Facility° NaatelLocation if Different) <br />#JAME <br />ADDRESS <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 I YEAR MO DAY <br />FROM I TO <br />Form Approved. <br />OMB No. 2040 -000 <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 />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />/ iV �) ' <br />PERMIT <br />REQUIREMENT1 <br />,jlf1J <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 />Icerlify under pen: dtyoflaw that this document and all attachments were <br />prepared under my direction or supervision in accordance with it 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 />TELEPHONE <br />DATE <br />r' <br />or those persons directly responsible for gathering the information, the infnrmalion <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />1 am aware that there are significant penalties for submitting false information, <br />including the possibilih of fine and imprisonment for knowing violations. <br />TYPED OR PRINTED <br />AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />AE I T i.La,s�I_L 6LIL I D6 LiMi ( WAI VL -D FUR W —YR) G "4 hiz PHECIP EVE,' i i <br />FART I. S. 6. ANY ADDITIONAL DATA SHALL BE SUPPLIED TO THE DIVISION WITHIN 48 FIOUPS. <br />EPA Form 3320 -1 (Rev. 3/99) Previous editions may be used. This is a 4 -part form. PAGE OF <br />y <br />