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PERMITTEE NAME/ADDRESS (Include Facility Aame/Loration iJUifferint) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO I I_ <br />C1 C Form Approved. <br />11 OMB No. 2040-0004 <br />R,eGf%vf-0 <br />J?? 2 ? 2Q09 <br />o? ??e,?amatlon, <br />10104"ti nn and $aieH <br />NOTE: Read Instructi4h"eTore completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX Y TYPE <br /> ANAL <br />SIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under my direction or snpersis6m in astiordance with a system designed <br /> to assure that qualified prv.amd properly gather and rsalwte the inrormati(m <br /> ahbmilled. Rased on m) inyuin or the W"jn or perWxu who manage the system. <br /> % re pon%ihlr for gathering the information, the information <br />h- persrahs di-fl <br />- <br /> . <br />: <br />submitted is, to the best of my knowledge and belief. trur. ncrurale, and rmnptete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am aware that there are significant penalties for submitting rater inrurmatirm. A <br />REA <br /> risonment fur knowing sedation. <br />-ibitits of fine- and im <br />in <br />ludin <br />the OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED p <br />p <br />c <br />g <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 /> <br />This is a 4-part fonn.