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PERMITTEE NAME/ADDRESS Qndude Faciliry NamY/Loeariaa ifOifferenQ
<br />NAME _
<br />ADDRESS L'~~-;= 1'"_. .I ;.-
<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLIJTAN! DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DIBCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~~ i ~ ' TO ') • ~~ ~ ~ 1
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<br />Form Approved.
<br />OMB No. 2040.0004
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<br />NOTE: Read Instructions before~co'mpleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX OF TYPE
<br />PARAMETER
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANaLrSts
<br /> SAMPLE ~ .. ... , .... ( I _ ~
<br /> MEASUREMENT
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<br />'L`:: 7 ~~~: 3.-~., V5. ~c REQUIREMENT E1I NjhuM. !{A j11I7 PI ,%J
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<br />.'I, ~'.i;i 'i; Lri- REQUIREMENT - -. - yt.+.. 34QX ~Yw QX ~ Y PfC,/L ON"'
<br />ir., ...~fL i+.~L` SAMPLE ~..='< ... .. ( 7C~
<br /> MEASUREMENT
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<br />I.i ~ 1 '-r D PERMIT C#r3 rdr4G r9#### ~ C4#### 3.0 6. D _ t't '. A't,`~/ N~~t`:
<br />- i.•L ~~ i ~ J '! 4t.'i'~ REQUIREMENT 300 R. A ti lil Y
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<br />. '., l~i :: I'~..i![' .,. SAMPLE ( i) ,;:Gros: .. r,: Vl >k r': ..;: r,.:k ~
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<br />;. L ~ . r ~ SAMPLE .. ( 1': 1 ~ ~. .. ,
<br />_:•i. MEASUREMENT
<br />I ~ i .. -i PERMIT ;<ua#a"# D - -. afar#;~:x# - #aaa#4 ~a+~xr#o,~: :. 8314Y I9 :.
<br />': i ,..j ; S a/ n L'! c REQUIREMENT IRS T N~ A X '~ -
<br />NAMERITLEPRINCIPALEXECUTIVE OFFICER Kenny under penalty of law that this daruvmerx and all attachmams were TELEPHONE DATE
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<br />' ~ ( Ll ~ (.~ J(! ' '.S e~q / prepared untler my tlmadion or supervision In accordance vnlh a system designed
<br />to azsure Ihat qualified personnel properly gather antl evaluaze the Inlormation -
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<br /> submitled. Based on my Inquiry of the person or persons who manage the system,
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<br />a. SIGNATUREOF PRINCIPAL EXECUTIVE // '
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<br />TYPED OR PRINTED I am aware That Nere era sigMCant penalties for submirong lelse information.
<br />indudin me ossibdi olfna and im nsonmant for knowm Nolaucns. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />. :1:'41. I..).': Lj".i... ..!L - ~ :'d '. -, P-.. "L•.. .. ~ ..._i,'. „! ~" ... .,I'... ..:° t~=il.' ~,.., ,-:::i' ~~y _
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<br />EPA Form 9320.1 ~(RE~~V 3/99) 'Previous editions m y be used. r ~ T IS IS A 4PART FORM PAGE j OF
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