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PERMITTEE NAME/ADDRESS (Include <br />Facility Name /Location if different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION W Nk, � z A6olA SP'AwN(22S Cz) ? I`i <br />ATTENTION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />(2 -16) (17 -19) Form Approved. <br />COG- COGS01529 do2--A Minor OMB No. 2040 -0004 <br />PERMIT NUMBER DISCHARGE NUMBER Approval expires 10 -31 -94 <br />F - Final <br />MONITORING PERIOD <br />l YEAR MO DAY YEAR MO DAY NO DISCHARGE V1 <br />FROM O TO <br />(20 -21) (22 -23) (24 -25) (26 -27) (28 -29) (30 -31) NOTE: Read instructions before completing this form. <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA FORM 3320 -1 (REV. 9 -a8) Previous editions may be used. <br />(REPLACES EPA FORM T -40 WHICH MAY NOT BE USED) <br />0000319503315 -1533 <br />PAGE 2 OF 2 <br />FREQUENCY <br />PARAMETER <br />(3 Card Only) QUANTITY OR LOADING <br />(4 Card Only) QUALITY OR CONCENTRATION <br />NO. <br />OF <br />SAMPLE <br />(32 -37) <br />(46 -53) (54 -61) <br />(38 -45) (46 -53) (54 -61) <br />EX <br />ANALYSIS <br />TYPE <br />(64 -68) <br />(69 -70) <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />SAMPLE <br />MEASUREMENT <br /># #x # # # <br /># # # ## <br /># # # # ## <br />PERMIT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />30 -D AVG <br /># <br /># # # # ## <br />REQUIREMENT <br /># # # ## <br /># # # # ## <br /># # # # ## <br />SAMPLE <br />MEASUREMENT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />PERMIT <br /># # # # ## <br /># # * # ## <br /># # # <br />,-D�y AV <br /># # # # ## <br /># # # ## <br />REQUIREMENT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />SAMPLE <br /># # # # # ## <br />## <br /># # ## <br /># ## <br />ki <br /># # # # ## <br />MEASUREMENT <br />MEASUREMENT <br />PERMIT <br /># # # # ## <br /># # #* <br /># # # ## <br />30 -DAY AVG <br />* # # #rk <br />A <br />## ## <br />Z01» <br />REQUIREMENT <br /># # ## <br /># # # ## <br />®N <br />SAMPLE <br />RFG! RM�fiI <br />p1V�S�pNOF SAFfi`( <br />MEASUREMENT <br /># # # ## <br /># # ## <br /># # # # ## <br />PERMIT <br />## # ## <br /># # # # ## <br /># # # # ## <br />30-DAY AVG <br /># # # # ## <br />M�N�NGpNQ <br /># # # ## <br />REQUIREME 7 <br /># ## # <br /># # # # ## <br />#x # # ## <br />SAMOLF It <br />MEASUREfik T <br /># # ## <br /># # # * ## <br /># # # # ## <br />PERMIT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />30 -DAY AVG <br /># # # # ## <br /># # # # ## <br />REQUIREMENIN <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />SAMPLE <br /># # # ## <br /># # #x ## <br /># # # # #t <br /># # #* <br />t # # # ## <br />MEASUREMENT <br /># # # # ## <br /># # # *# <br /># # # # ## <br />PERMIT <br /># # # # ## <br /># # # # ## <br />30 -DAY AVG <br /># # # # ## <br /># # # ## k <br />REQUIREMENT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />SAMPLE <br /># # # # ## <br /># # # # ## <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />MEASUREMENT <br /># # # # ## <br /># # # # ## <br /># # # # ## <br />PERMIT <br /># # # # ## <br /># # # # ## <br /># # # ## <br /># # # # ## <br />30 -DAY AVG <br /># # # # ## <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON MY <br />TELEPHONE <br />DATE <br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />-- <br />THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION IS TRUE, ACCU- <br />J <br />RATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES <br />l�� G/ <br />FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE <br />-� <br />L <br />It� la. -lam <br />AND IMPRISONMENT. SEE 18 U.S.C. § 1001 AND 33 U.S.C. § 1319. <br />(Penalties under these statutes may include tines up to $10,000 and or maximum <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />AREA <br />TYPED OR PRINTED <br />m <br />mpnsonent of between 6 months and 5 years ) <br />OFFICER OR AUTHORIZED AGENT <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA FORM 3320 -1 (REV. 9 -a8) Previous editions may be used. <br />(REPLACES EPA FORM T -40 WHICH MAY NOT BE USED) <br />0000319503315 -1533 <br />PAGE 2 OF 2 <br />