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PERMrTTEE NAMEIADDRESS Onchidc FadfirpSamc(La-tion if Different) <br />NAME <br />ADDRESS <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREOUENCY <br />SAMPLE <br />>< <br />EX <br />FACILITY <br />V. <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM WDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />I PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR M4 DAY YEAR I MO, I DAY- <br />FROM ;pf)"31 V -7* 1 0-f- I TO [Ja7N 0 <br />Form Approved. <br />OMB No. 2040-0004 <br />C. <br />NOTE: Read Instructions before this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREOUENCY <br />SAMPLE <br />>< <br />EX <br />OF <br />ANALYSIS <br />TYPE <br />AVERAGE <br />MAXIMUM' <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />SAMPLE <br />MEASUREMENT <br />v A <br />.REQUIREMENT' <br />11C <br />SAMPLE <br />14r <br />MEASUREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT:`.-r.'' <br />VAL <br />SAMPLE <br />MEASUREMENT <br />4. - <br />.:•t. -.:, -F•7: <br />-7,77,777- <br />A U <br />;.REQUIREMENT <br />*.5" - <br />2`10:1,,A AV9 <br />U <br />SAMPLE <br />4.7.- <br />MEASUREMENT <br />4 A <br />�70,-=S V 'j'a <br />REQUIREMENT, <br />SAMPLE <br />R=-A*�-NENT F LAN!- <br />MEASUREMENT <br />r� <br />, -'-PEAMrT­--'," <br />",:-e -,C' -,t W <br />W W <br />VALIj-15 <br />REQUIREMENT: <br />T, <br />'?'a- <br />SAMPLE <br />..... <br />SEA V. H L, <br />MEASUREMENT <br />7 <br />-4REQUIREMENT- <br />DATE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify mice penwty onaw that ti& documentand wituttachment%wom <br />prepared under my direction or %'upervWoa in accordance with a xyhum degigned <br />ou" <br />' "oee that qualified PerSOond ProlKely AWWr and evaluate the Information <br />%L3bndt#A-d. lla�d on my inquiry of the person or Persons who manage the h)Wcm, <br />Information <br />ELEPHONE <br />or diose, persom direcay resporn;ible rot gvdieriou the information. the <br />ig• knowledge belicE <br />f 7W7c?,X- <br />jbmitted to the bel or my und true• accurate. and compkic <br />I am aware Mut there are sMairmad ponaltics for milunitting tube information. <br />Including Mo.- pm%ibllily or fine- and impriwament rot knowing vioudom. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT AREA I NUMBER <br />TYPED OR PRINTED <br />YEARI MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />,;k F." �Z -:-!E :4, .. F, <br />— 0 - - � 2r I <br />EPA Form 3320-1 (Rev. V99) Previous editions may be used. .1 -� - Pijr'p&rM. PAGE ?OF <br />