Epa Form 3320-1 - Discharge Monitoring Report (Dmr)

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NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
PERMITTEE NAME/ADDRESS
Form Approved.
(Include Facility Name/Location if Different)
DISCHARGE MONITORING REPORT (DMR)
NAME
OMB No. 2040-0004
ADDRESS
PERMIT NUMBER
DISCHARGE NUMBER
MONITORING PERIOD
Check here if No Discharge
YEAR
MO
DAY
YEAR
MO
DAY
FACILITY
LOCATION
FROM
TO
NOTE: Read Instructions before completing this form
QUANTITY OR LOADING
QUALITY OR CONCENTRATION
FREQUENCY
NO.
PARAMETER
SAMPLE
OF
EX
TYPE
ANALYSIS
VALUE
VALUE
UNITS
VALUE
VALUE
VALUE
UNITS
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
SAMPLE
MEASUREMENT
PERMIT
REQUIREMENT
NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
TELEPHONE
DATE
I CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS WERE PREPARED
UNDER MY DIRECTION OR SUPERVISION IN ACCORDANCE WITH A SYSTEM DESIGNED TO ASSURE
THAT QUALIFIED PERSONNEL PROPERLY GATHER AND EVALUATE THE INFORMATION SUBMITTED.
BASED ON MY INQUIRY OF THE PERSON OR PERSONS WHO MANAGE THE SYSTEM, OR THOSE
PERSONS DIRECTLY RESPONSIBLE FOR GATHERING THE INFORMATION, THE INFORMATION
SUBMITTED IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND COMPLETE.
I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION,
INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR KNOWING VIOLATIONS.
SIGNATURE OF PRINCIPAL EXECUTIVE
AREA
OFFICER OR AUTHORIZED AGENT
NUMBER
YEAR
MO
DAY
TYPED OR PRINTED
CODE
COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
EPA Form 3320-1
PAGE
OF

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