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PERMITTEE NAME/ADDRESS(rnctude Factttry Nmne/Locunon iJDigerorl)
<br />NAME
<br />BLUg ;~OL'~N^AI!I ii is =:i;i~Yr INC•
<br />ADDRESSD ,. S ~ P. A D',~ ^' I !a F.
<br />I{ FACILITY H A 4 .; L Y ~ J ~~ j ,, ;;
<br />I LOCATION
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<br />PARAMETER
<br />3:);), ~-GAY SAMPLE
<br />(1 ;1 :~ ;. ~ , - ~ MEASUREMENT
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<br />'Ji)e S-DAY SAMPLE
<br />(1 J I% E v , C) MEASUREMENT
<br />;D~IC I ~ u
<br />
<br />iJLi Oar :I~TnL SAMPLE
<br />U E P F t: L~ E I MEASUREMENT
<br />liiSiU ;, L~ U
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<br />rJLIDi, T~•:,4L SAMPLE
<br />~J jp~N;~. F; I~ MEASUREMENT
<br />iU0.1U I ~ 0
<br />FFLUihT :;k 55 PALIiF.
<br />'LJhe iM CONDUIT OP SAMPLE
<br />N~ it ° r• e: 5? ": E\ T P L A N T MEASUREMENT
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<br />f FL'U i''.: f;H055 VALUE.
<br /> SAMPLE
<br />SAMPLE
<br />AVERAGE
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESJ Form Approved.
<br />DISCNARGE MONITORING REPORT (OMR) OMB ND. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NuN1eER F _ r ; ,• E L F; ~~ L R
<br />MONITORI GPERIOD :;.%'i'.:~. "~ _A.T°F'+T Pi.AL' ,
<br />Y MO DAY YEAR MO DAY
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<br />NOTE: Read Instructions befo~e~pmpleting this form.
<br />Y OR LOADING pUANTITY OR CONCENTRATION NO. FREODENC SAMPLE
<br />EX of TYPE
<br />MAXIMUM UN MINIMUM AVERAGE MAXIMUM UNITS avacysrs
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<br /> NAMERITI.E PRINCIPAL EXECUTIVE OFFICER ICenify under penalty of law ihm this document entl ell aaachmerHS were
<br />prepared under m
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<br />ervision in armmance with a s
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<br />d TELEPHONE DATE
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<br />b assure that qualifietl personnel properly gaNer and eraluate the inlonnation
<br /> ..1 submittetl. BaeBd on my inquiry of the person or persons who manage the system, ~
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<br /> - or Ncee persons directly responsible br gathering Ne iMOrmallon, the IMOrmMion ~~
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<br />a SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />Inclutlin the alblll olfina and im risonmeM ror knowin violations. OFFICER OR AUTNORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence ell attachments here)
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<br />EPA Form 3320.1 (REV 3/99) Previous ediGOns may be used. THIS lS A 4PART FORM PAGE OF
<br />00724/OOQ,~,~7~1350 l
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