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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMRJ OMB No. 2040-0004
<br />PERMIT NUMBER DISCHARGE NUMBER _ ,: I . ~ ;
<br />MONITORING PERIOD ' ' ' I -, ` LI , i' ~., ":- 7 ", .., 'n A S ,~
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<br />NOTE: Read Instructions betoie ompleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />i SIGNATURE OF PRINCIPAL EXECUTIVE r ~ ~' S9
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<br />TYPED OR PRINTED alse ln
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<br />lam aware that Nere are signRicaM penallies for submitting
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<br />inclutlin the oasibili of line and ,m risonment br knowin wplatipna. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form 3320-t (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
<br />00573/000717-13SJ 1
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