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PERMITTEE NAME/ADDRESS pnclede Fpnlirv Name/Lacahon fDifferenq
<br />NAME
<br />a LUc !:?U iif elti ~ ~Fi;~Y, IN;,.
<br />ADDRESSU ;: ~ i" l; q :) -: ~~ 1 !ti ii
<br />FACILITY r. d 8 "; i. 1 .. .. h i ~ 4
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~ 1 •: i -.) TO V 1 'v . ~
<br />Forth Approved.
<br />OMB No. 2040-0004
<br />'!IsU:;
<br />(SJ.i2 Nii)
<br />- F'i:,AL
<br />.NOTE: Read Instructions before~b7n(pleting this form.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX of TYPE
<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALtslS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l Cendy udder penelry of law that this tlocument antl all anachments were
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<br />d TELEPHONE DATE
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<br />to assure that quaffed personnel properly gather end evaluate the mlormation
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<br />i subminetl. Based on my inquiry of the person or persons who manage the system,
<br /> Vie Inlonnation
<br />or those persons tlireclly responsible for gathering the inlonnation
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<br />submktetl is, to the best or my knowledge and belief, true, accurate. end complete.
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />' ~7~
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<br />TYPED OR PRINTED I em aware Nat there are significant penalties
<br />or submining
<br />alse
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<br />rmakon,
<br />includin the ssibili of fine and lm risonmant for knowin vmlations, OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachments here)
<br />.. ..'LU:..+f h°.P L:,: Ci'i _t ~i -.. _.. (. Li:_. .`, gNALY ;,.~ i. r, L'.?(; !'. !'.. ,! .^%T ii LY `i r.3ni: I:L`_':i ~ i'~ - !i.. .. 1`: -. .. ~ ,
<br />. .5'dA.1;.. J::;:U35.
<br />EPA Form 3320-1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
<br />'?'17;>:1/ ; 11717-i •.- 1
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