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PERMITTEE NAME/ADDRESS /Tnclude Faci(ip~Name/LOCafion ifOdnenrJ
<br />NAME ,S LOS ~"J'J ,4;AIN ::N:-??,Y, iN;:.
<br />ADDRESS) t~;.jq);1 `INh
<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLl1TANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMRJ
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ., 1 (1 l TO ')1 rJ 1 3 1
<br />Form Approved.
<br />OMB No. 20440004
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<br />ANOTE: Read Instructions before'i;ompleting this form.
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<br /> OUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FgEOUENC SAMPLE
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Ceniy urMer penalry of law that this tlocument antl all anacnments were TELEPHONE DATE
<br /> prepared under my tlirect~on or supervision in accordance wile a system tlesignetl
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<br />S~ to assure diet quNifietl pereonnel properly gather end evaluate the information
<br />. D 7 / submitletl. eased on my inquiry M the person or persons who manage the system,
<br />the information
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE (~
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<br />TYPED PRINTED I am aware that there are sign~fcant penalties for submitting false inbrmation,
<br />includin the sibili of floe antl im risanment for knowin violations.
<br />OFFICER OR AUTHORIZED AGENT q
<br />D
<br />NUMBER
<br />YEAR
<br />MD
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIO'.ATIUNS (Reverence a)7 attacnmenrs nere)
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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
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