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or=o••l-SEE NAME/ADDRESS (Include Facility NameJlarnnon lfDffereu) <br />I~ <br />t/• <br />rn <br />I~ ION <br />I~ <br />l <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMq) <br />PERMIT NUMBER DISCHARGE NUMBER ~ <br />" ~' ' MON170RING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ". '1 I TO r , ,- 1 +' <br />Form Approved. <br />OMB No. 2040-0004 <br />-/ <br />. _ _r... .,.. . <br />NOTE:,Read Instructions befo~~pleting this form. <br />p QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FgEOUENC SAMPLE <br />PARAMETER EX of TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE ~ ' ~ ~' ~ ~ '- ~ ( ..'~ <br /> MEASUREMENT <br />~~ ~., i y S. PERMIT - <br />~ <br />~) <br />; <br />( REQUIREMENT - <br />_ <br />. <br />_ <br />~ _ <br />' r ~ i i _. ~~ i. SAMPLE '~ ~ t ~ ~ ~ ( ~' r~ <br /> MEASUREMENT <br />' '. J . U ~ PERMIT . ;r •.:+-.: ~.: .. • <br />.', J . ~ '..7 i : :. ,I <br />. .. REQUIREMENT - <br />a <br />t <br />L <br />J SAMPLE .~~-.... .n ~~:, ^•.~..: '. <br />( <br />-'i <br /> MEASUREMENT <br />~ ! ~ i G :~ PERMIT .. ... . . <br />' ~ l' • ~ . ~ REQUIREMENT <br />~/; <br />..L~,e L' .b. SAMPLE { C ~:~ .. ~ - .. <br />,, ,,,; ~„ - _ ~~ ,';- MEASUREMENT <br />. (~ ~ ~ t' r_ L ~ PERMIT .. <br />' "LD . ". - - 7:. :. 1: REQUIREMENT - ~,r ~ - .. <br />L7')~s .. .. SAMPLE ~ ;:r .. r ;~ <br />t r <br />', , . , (, L ' ~ MEASUREMENT <br />/ ,' .' ' - - PERMIT .. <br />' - - :. ~ ~.:; •. ' I REQUIREMENT .. ~ ~ ~ ~ , <br />_ ~ .:::S" SAMPLE ( ~ } .. <br />y '.~ _ MEASUREMENT <br />i - -. ~ U PERMIT ..... ~, I c = ~ ... _ <br />L'1 _: - ;; 7'i: ".'I REQUIREMENT - - :r~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICaraty untlar penalty Mlaw that this tlocumant antl all attachments were TELEPHONE DATE <br /> <br />- <br />'l prepare0 under my tlireciion or supernsion In accortlance with a system tlesigned <br />to assure that qualified personnel properly gather and evaluate Ne intormaaon / / <br />e ~ <br />. ~ <br />, ~ r ~ <br />submiaed <br />Besetl on my inquiry or the person a persons who menage the system ,~~ <br />/• ~ <br />~ ~ <br />~ <br />~ <br /> . <br />, <br />or (hose persona tllrecYly responsible br gathenng the Irtlonnetion <br />Ne Intormalion G l , _ <br />I ( ~ I <br />~~ r <br />/ ~ U , <br />- <br />~ ~ <br />~ , <br />N <br />titt <br />tl i <br />t <br />b <br />t W <br />k <br />l <br />tl <br />li <br />l <br />t <br />t <br />M <br />l <br />h <br />d b _ <br />~ <br />1 ~~ n <br />. , - <br />~y~ ~ , , ~ eu <br />r <br />e <br />s , <br />e <br />es <br />my <br />now <br />e <br />ge en <br />, <br />rue, accura <br />e, e <br />o <br />e <br />e <br />comp <br />ete. SIGNATURE OF PRINCIPAL E%ECUTIVE : ~ <br /> <br />TYPED OR PRINTED lam aware that Nere era significant penalties for submising false inlormation, <br />includin Ne sibili of fine and im dsonmern br krwwin violations. OFFICER OR AUTHORIZED AGENT AR <br />NUMBER <br />YEAR <br />MO <br />DAY <br />UUMMtN 15 ANU EXPLANA I IUN UI- ANY VIULA I IUNS (HBteTenCe all attachments here) <br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. ~ _ _ THIS IS A 4-PART FORM PAGE y OF <br />