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PERMITTEE NAME/ADDRESS Qnclude Faeiliry Name2acahon i/Differen0
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<br />ADDRESSp.;g EkAJ) wINc
<br />FACILITY HAY~LY ,) '1.r~4?
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 1 v l TO J 1 1)1 3]
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before c"3mpleting this form.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />ER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS nHnr-rsrs
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<br />NAMErTITLE PRINCIPAL EXECUTNE OFFICER I CerLy under penalty of law that Ihls document and all attachments were
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<br />. SIGNATURE OF PRINCIPAL EXECUTIVE O OZ ZG
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<br />TYPEd'OR PRINTED I errl aware Nat Nere ere slgnffcent penalties for submitting lalse information,
<br />inclutlin the ossibil' olfine antl im risonment for knowin violations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form~3320.1 (REV 3/59 y revious editions may be used. T IS IS A 4-PART FORM PAGE OF
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