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PERMITTEE NAME/ADDRESS ()ndude Fonliry Namr/Lacorion ijDiperenq <br />NAME _ <br />ADDRESS ~ - <br />.~ _ _ .. , ., 1 .. <br />FaciuTY ,~:; - <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATON SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 />NOTE: Read Instructions before'cdmpleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX of IYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aN'tlvsls <br />- - J ~ . C SAMPLE <br />__ _ MEASUREMENT <br />'- PERMR _ <br />- r„) REQUIREMENT <br />I ~.- : L C SAMPLE ~ ~ ~ .. <br />- - MEASUREMENT <br />._ ,_ 't PERMIT ... <br />r ~ - - ~• REpUIREMENT ~ - <br />,~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REpUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICertiry antler penelry or law roar Nis OOCUment entl ell attaehments were <br />ntler <br />NSi <br />i <br />n <br />tl <br />tltr <br />[i <br />I <br />tl <br />ith <br />tl <br />0 TELEPHONE DATE <br /> <br />// g <br />pmpere <br />a <br />my <br />ec <br />on or super <br />on <br />n arsor <br />ance w <br />a system <br />es <br />e <br />la assure rhat qualified pereonrrel properly gather entl eteluata the hlorrnaGan /, <br />~ _ r <br />~' <br />te <br />• <br />' ~ rr !), ~;.~ ~, eubmlttetl. easetl on my lnqulry al Ne parson or persore who maroge the system, <br />or those rsons tlir <br />pe eglY resppnelble br geNerine Na IMOrmatlan <br />Ne Inb~metlon . I <br />! <br />l. -- <br />~ ~ , /_ . ,_ <br />~ <br />I I ~ ~ t <br />r <br />./ <br />_ <br />L' <br />."1 r _ .l ~ r. , , <br />submitted Is , to the best of my knowletlpe entl belief, true, eccureta, entl Wmplete. <br />I <br />h SIGNATURE OF PRINCIPAL EXECUTIVE . s <br /> <br />YPED OR PRINTED em aware I <br />ffi mere ere sipnifram peneltlee br submitting false Inlormaeon, OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />T Includin the ssibili or fine and im risonmern br krwwi wolations. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />_ r - a .. T .. _ 1 v <br />EPA Form 3320-1 (REV 3/99) Previous editions may be used. ~ ' <br />~ i. ~ ~ . 1 <br />. .. t <br />" , _ THIS IS A 4PART FORM PAGE OF <br />