Laserfiche WebLink
PERMITTEE NAME/ADDRESS pnc(ude Faci(iry Nmne/Locarbn IfDi$erenq <br />NAME ., I . _ <br />ADDRESS ~~ - <br />, <br />t <br />FACiuTY _.. - - <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />:~~ <br />NOTE: Read Instructions before Ctlmpleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX of TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 'w'u~ <br /> SAMPLE ~ ~ "" <br /> MEASUREMENT <br />•)t..4a ;= iy PERMIT ~ - - .-. ~ - - <br />- _, ~~ a ~ - REQUIREMENT , - <br />_ ._. ~ .'.'~. SAMPLE .. <br />,_ ~ MEASUREMENT I <br />. -... 7 PERMIT - ~ - - <br />~_~ ~ - .i ~ r ~ • • REQUIREMENT ~ ~ ; ~ . <br />- - _ ~ ~ SAMPLE ~ ~ ~ ` <br /> MEASUREMENT <br />., .. PERMfi •- ~ - <br />~~ - ~ -_ •I REQUIREMENT ~ - I <br />_ ~ ~ .. SAMPLE ~ ~ ' <br />t <br />r ~~ <br />I MEASUREMENT <br />.- - 'i PERMIT - - , <br />I, _ REQUIREMENT e - <br /> SAMPLE <br /> MEASUREMENT <br />.. _ ... ~ .. PERMfi .. ~~ . , <br />• _ REQUIREMENT <br />.. " , ~ ... ., f SAMPLE . ; <br />• -~ ~ - <br />_ ._ , MEASUREMENT <br />-~ PERMIT - "" <br />r •. ~ REQUIREMENT - " -~ _ <br />' ~ ~ I ' / ~ SAMPLE " " , <br /> MEASUREMENT <br />.-, It PERMR _ <br />- I ~ ~ REQUIREMENT ~~ <br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER I Certify unoer penalry d law that this ooamem and all attachmems were ~ , <br />~ TELEPHONE DATE <br />~ prepereo unoer my tliredion or supervision in accordance with a system tlesignad i <br />~ <br />" <br />. ~ <br />~ <br />f <br />' <br />~ t "" b enure Net qualifieo pereonnel properly gather entl evaluaze the Inlonnation _. _ _ ~ ~ <br />I / , " <br />- O a •- <br />.. <br />/ <br />-• eubmMeo. Beseo on my inquiry or the pereon ar pereare who menage the system, ~ / j/ 4 - -- - ~. <br />~ <br />J <br />r~ or those persona direc0y reapontible br geNmng the IMOrmetlon <br />Ne i,MO,megon 1 _ <br />1 h <br />I <br />r <br />" , /- <br />Y rJ I I <br />'t ~ . ,, _ „(~~ ~ <br />~ r, , submittetl ia, to Ne beat of my knowledge ano belief, true, axumte, ano complete. SIGNATURE OF PRINCIPAL EXECUTIVE I !~. , <br />TYPED Ofl PRINTED lam aware Nat Hare era significant perWties br submining false inbrmation, <br />Incluoin the ossibili of fine ano im risonment br knowin violations OFFICER OR AUTHORIZED AGENT D NUMBER YEAF1 MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Here2nCe ell attachments here) <br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. ~ '' "- ' ~ - THIS 15 A 4-PART FORM' PAGE OF <br />