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PERMITTEE NAME/ADDRESS Qnclrrde Faciliry NamNCocarian i/Diperenq
<br />NAME •., 1.., °~J.. ~,°4T_- ,.L .r, T'.-.
<br />ADDRESS ^ . ~.. ;; ,; ~ ~. ~ ,
<br />.tJ/ ~ 1' .'.'Y _.- ~ _
<br />FACILITY f . •, _ L ~ 1 ,, i
<br />LOCATION
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<br />NATIONAL POLLUTAPfr DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMA)
<br />~'~r.9nt~', i+ ,~ s
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 1 _ _ TO
<br />Form Approved.
<br />OM8 No. 2040-0004
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<br />NOSE: Read Instrudions~before o tpleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FAEOUENC SAMPLE
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<br />PARAMETER
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~'/s
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<br /> MEASUREMENT
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<br />.; I .. ~ ~ MEASUREMENT
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<br />(A ; ;~„) MEASUREMENT
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICeniy under penalry of Ww that Nis document erW all a[IachmeMa ware TELEPHQNE DATE
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<br />91GNATURE OF PRINCIPAL E%ECUTIVE
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<br />TYPED OR PRINTED I em aware that Ihare ere significeM penallles for submitting false information,
<br />Incwdin the sbili of tine and .m risonment for knowin vioiamns. OFFICER Ofl AUTHORIZED AGENT A
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence aJl atracnmenrs Here)
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<br />EPA Form~9320-1 ~((7EV 3/99) Previous ~editions'may be used. (1 I] y 5 3 (~ U G 7 i ] ISi@)A,4-PART FORM PAGE 1 OF
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