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PERMITTEE NAME/ADDRESS (Indvde Facility Name/Locahon iJDifferenq
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<br />ADDRESS, ~, .` + , ~~ i .;
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Fortn Approved.
<br />DISCHARGE MONITORING REPORT (DMA) OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER (~ _~;. IL
<br />MONITORING PERIOD "- ~~ ~ - • -~ ~ ~ • ~" r
<br />YEAR MO DAY YEAR MO DAY
<br />FROM t I. .. _! TO J i. ,. y _. , ;.. ,_ ,..1 _ :..:
<br />' NOTE: Read Instructions before rr~pleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FgEOUENC SAMPLE
<br /> EX of TYPE
<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
<br />' SAMPLE ..... .... ( I "'
<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l c¢nny untlor penairy of law Nat Viis tlocumenl antl ell aPachmank were
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<br />. 1¢azsure Viet qualified personnel properly gather entl evaluate the inlonnation _ -~_,~
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<br />o SIGNATURE OF PRINCIPAL EXECUTIVE '~ 4' ! 1
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<br />r O I o' S.
<br />TYPED OR
<br />PRINTED lam aware Nat there era significant penalties for sudrroVing lake iNOrmaton, OFFICER OR AUTHORIZED AGENT ~` NUMBER YEAR MO DAY
<br /> includin the ¢ssibil~ of fin¢ antl im risonment br knowin W¢lations.
<br />COMMENTS AND EXPLANATION OF ANY VIOIATIONS (Reference all attachments here)
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<br />SPA F'oiin~3~3~0-1 {REI/ 3J9~)` Prev(ous a itions may be used. THIS IS A 4PART FORM PAGE OF
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