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<br />PERMITTEE NAME/ADDRESS (Include Facilip• Nume/GOCanon iJDiffereng
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<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NFDES)
<br />DISCHARGE MONITORING REPORT (OMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM •' ' % ! TO i 1 ~ l -~
<br />Fonn Approved.
<br />OMB No. 2040-0004
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<br />- -NOTE: Read Instructions before completing this form.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I Ceniy under penalty of law that mrs documem ono an enachments were TELEPHONE DATE
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<br />c pmparetl under my tlireclion rr supervision in axortlenca with a system das~gnetl
<br />to assure that qualified personnel properly pother antl evaluate the information
<br />. eubminetl. Basetl on my inquiry of the person or persons who manage the system,
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<br />or those persons directly responsible br gathering the irrtonnation
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<br />submided is , to the best al m knawled antl belief, We. accurate, mtd complete.
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE +
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<br />TYPED OR PRINTED I ~^ aware that Thera ere significant penalLes for submitting false Information,
<br />indudin the ssibili of tine ono im risonmenl for knpwin wolations. OFFICER OR AUTHORIZED AGENT A
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS fRe/erence all attacnmenfs Here)
<br />,.._ J!'AL '! ..L•CIT_ i..L '' 'I' ~, 'l ',. ;`T ... .r..-l. .,Ji.i„+. ..I..it A~7L_ %l ,. C=I~YR,?v4: PH=Clr .'r -
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<br />EPA Form 3320.1 (REV 3/99) VPrevious e ~ pions may be used. 0 0 6 11 / 06 0 71T1-IISl~q PART FORM PAGE 1 OF
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