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PERMITTEE NAME/ADDRESS {Unlade Facffily NemdLowdon if Different) <br />NAME 7-- <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT oracKARGE Eumm-nom symm (NPDES) <br />DISCHARGE MONITORING REPORT (DUR) <br />PERMIT NUMBER I I DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM Y��WAu TO IMM DAY. <br />R I MO. I <br />ZaAl 0_--j I Q * I 12 <br />Form Approved. <br />OMB No. 2040-0004 <br />F 7 4 A, L <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREOUENCY <br />SAMPLE <br />EX <br />OF Is <br />TYPE <br />I <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />SAMPLE <br />MEASUREMENT <br />PERMIT., <br />-7777, <br />-;r -.Z- -s- -;r -.z <br />A;; <br />;JL U2 <br />A <br />REQUIREME14T <br />:Y!A X I"ll '-TM <br />C-�,J <br />SAMPLE <br />• j 5 P EN D. =-r- <br />MEASUREMENT <br />RE61UIREMENT- <br />30DA tk, <br />f <br />(r,,-46�f -y- ix <br />MONITH <br />SAMPLE <br />MEASUREMENT <br />PERArr' <br />717- <br />V. 5 <br />tAr <br />70., tt • <br />x4, -t-, <br />REOUlMOBitT <br />LY <br />MONTI;--i <br />!--N <br />SAMPLE <br />MEASUREMENT <br />P ER <br />2r 714, <br />.5. <br />-17) 1 7 <br />i-=7Ft-UEN7 CPR`-'�ES VAL.`j;-�lREQUIREMENT <br />SODA AVG <br />SAMPLE <br />MEASUREMENT <br />:E .2 <br />:r W"!�r W <br />C V <br />4.1 <br />ROSS <br />'rAl.iLy MIV <br />SAMPLE <br />-.;r W, <br />-F-*:=NT FLAW' <br />MEASUREMENT <br />'E'." <br />PRM <br />•)f" l"R- W WW, <br />-W 'Ir <br />EFF-i '= `r- G�! 9 T- B 5 t,�;AL-,,;-=�.REQUIRSMWT- <br />SAMPLE <br />73777 -7 <br />f <br />Cu q <br />MEASUREMENT <br />MI <br />lzi"—d <br />x•:, -;::J <br />- <br />1 REQUIREMENT <br />T <br />300i:�. AV <br />x <br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify antler penalty or law that thk doctunent and all attachomms were <br />prepared under my direction or m2perviNioa in wcordunce with a "m dv igoetf <br />to aw%urc that qualifiLd persormet properly gatlier ami cvduale the information <br />TELEPHONE <br />DATE <br />bminc4l- Based go my Inquiry of the perxim or per%ons who maw*v the %pitem, <br />or chose permmis din-cdy for 12CIlLridn the information. the WfOrMaliOn <br />j EDAY <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />OFFICER OR AUTHORQW AGENT <br />submitted 6. to the hw4 of my kno-W-dAt and W- icl� true° acturatc, a" complete. <br />I am aware that lbere penaltieN for %ubmitting fh6e information. <br />including the pcKvibility of riot and imprNonment ror knowing vidatiow. <br />TYPED OR PRINTED <br />AREA <br />CODE <br />NUMBER <br />YEAR <br />, <br />GUOMMENT5 AND EXPLANATION Or- ANY VIOLATIONS (Kererenm- an atract7ments nere) <br />712 BURD'EN CF- PiROOF RE2UIREMIElk"Is <br />C — y ?., Z C 1 P V E N -Z:-. E <br />A-NY 2--T4 <br />EPA Form 3320.1 (Rev 3/99) Previous editions may be used. PAGE 5OF <br />