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PERMITTEE NAME/ADDRESS (Inclde Faciliry Nmne/Locorjon ifDiffererr)
<br />NAME
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<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMA)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING 1?ERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~~ ~ TO
<br />Form Approved.
<br />OMB No. 2040-0004
<br />°:"%OY
<br />(SUB;: Y4)
<br />- ~ -NOTE: Rears Insfructlons befo~e~pleting this form.
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<br /> QUANTITY OR LO G QUANTITY OR CONCENTRATION NO. FaEOUENC SAMPLE
<br />PARAMETER EX of TYPE
<br /> AVERAGE MAXIMU ITS MINIMUM AVERAGE MAXIMUM UNITS AfyALYSIS
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICertity under penalry of law that this tlocument and all attachments were TELEPHONE DATE
<br />prepared under my direction or supervision in accordance wish a system designed
<br />s-~ ~ f'/" / C ~ / ~ j-1 ~~ ~ b assure that qualified personnel properly gather end evaluate the iMarmalion
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<br />eubmlttetl. eased on my Inquiry of the person or parsons who manage
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<br />' SIGNATURE OF PRINCIPAL EJ(ECUTIVE V
<br />Ism aware Net there ere significant peneltlee lcrsubmitbng salsa lnfomletion,
<br />TYPED RPRINTED Includin the sibll' Mfine and im risonment br knowin violations. OFFICER OR AUTHOR12ED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) ,
<br />JiL :: .~R.'As:. I,;?'Jrf:..;-.~Ft': I.: .1. Fe ~ Y.I. NT=1.Y -5:'.^L: KG .~?':~i:TIC~_-1..:.9 PC 7iI.
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<br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
<br />00628/000717-1350 1
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