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PERMITTEE NAME/ADDRESS pnclrrde Facility NamdLocarias ifDl$ermrJ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FOrm AppfOVed.
<br />NAME DISCHARGE MONITORING REPORT (DMRJ OMB No. 2040-0004
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<br />PERMIT NUMBER OISCHARGE NUMBER
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<br />FACILITY ~, .iN ~..l "4 Ir'U4H MONITORING PERIOD `~_i LOADOU2 TO RF.P it AS.u
<br />LOCATION Y MO DAY YEAR MO DAY _
<br />FROM 0 ,. To 0. J5 31 ~ ~~ ~"~o DISCHARC'r- ~~~ ~=;,::t
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<br /> NAME/TITLE PRINCIPAL EXECUTNE OFFICER ICeNry under penally al law that t his document antl all attachments were TELEPHONE DATE
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<br />ete. SIGNATURE OF PRINCIPAL El(ECUTIVE I
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<br />TYP OR PRINTED I em aware that there ere signHipns penalties for submltling halsa inbrma[lon,
<br />Includln the ssib~li of line antl im risonment for knowin violations.
<br />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 3340.1 (REV 3/99) PreYlous editions may be used.
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