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PERMITTEE NAME/ADDRESS pncfude Fanliry Name/Lorn(ion ifDi$erenq <br />NAME <br />ADDRESS ~, ~ ~ ~ ~ _ - ~ - ~ r ~ ~ ~ ~~ <br />FAC W TY ' <br />LOCATION <br />r. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) FOrm Approved. <br />DISCHARGE MONITORING REPORT (DMRJ OMB No. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER ~ _ ~ ~ I <br />MONITORING PERIOD - ~ ~ ~ ~ ~ ~ .. <br />YEAR MO DAY YEAR MO DAY <br />FROM TO - ~ ~ ~ - <br />NOTE: Read Instructions before completing 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 A~-t'SIS <br />- ~ SAMPLE ~ '-' ~ ~ ~ ~ ~ ~ ' <br /> MEASUREMENT <br />. ,. ~ ~ f PERMIT -• ~ ~ -. - :. ,a Y .._ . - <br /> REQUIREMENT r - . ~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUAEMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br />NAMERITLE PRINCIPAL IXECUTIVE OFFICER ICanity under penalry of law tfw Nis document and ell atrechmame were <br />l <br />d <br />l <br />I , ~ <br />r TELEPHONE DATE <br />~l prepare <br />under my direction or supaMs <br />on <br />n accordance with a system dea <br />gnetl <br />l <br />d <br />h <br />. <br />' <br />- to eswra IhM qua <br />y gat <br />ified personnel pmpe <br />er and evaluate Ne information I <br />•• ~ ~ r <br />~) : _- r <br />1 ~ - ' ~ • ~'- au6mtttetl. eased on my Inquiry of Ne parson or pertons who menage the system, , , ~ ~ - - -~ <br />~ ~ t <br />~ ~T ' <br /> or Mwe persons directly reeponslGle br geNedng Ne inlornatlon <br />the IMOmiazlon ' <br />' l: ~ :~ - <br />I , <br />l <br />b <br />tl b <br />N <br />f <br />I <br />tl <br />d b <br />l ~, <br />I I , ~ <br />. <br />/ su <br />mme <br />, tp <br />my <br />mowie <br />ge en <br />elie <br />,lme, eccuraze, end cpmp <br />ere. <br />a best o SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />TYPED OR PRINTED lam aware that there ere signACant peneWes for subm~ninp false inbrmation, OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br /> Inclutlin the oasibili W fine end im risonmem br knowln violations. D <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />,. ~ -- . ) <br />EPA-Form 332o-1 (REV 3/99) Previous edittons may be used. ~ ~ ~ THIS IS A 4-PART FORM ~ PAGE OF <br />