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PEgMITTEE NAME/ADDRESS (lnclyde Facility Name/%ocanon yDiffercnq <br />NAME _ <br />r-.:. t.~- .. <br />ADDRESS - - -~ <br />FACILJTY ~ ~' <br />LOCATION <br />NATIONAL POLLl1TANT DISCHARGE ELIMINATION SYSTEM MRDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) OM8 NO. 2(}40-0004 <br />PERMIT NUMBER DISCHARGE NUMBER ( _ ' <br />MONITORING PERIOD . ~ ~ _ <br />YEAR MO DAY YEAR MO DAY <br />FROM - -- - ., TO - _ . ..'~'~` .. .. <br />.; ! p r, f , ~ , ,I , - ~ ~~ NOTE: Read Instructions before~zon{pleting 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 'wursis <br />_ : ~ , - ~. ~ SAMPLE .. <br />~~ - - MEASUREMENT <br />'~ PERMIT -- <br />-, r~ ~ ~ ~ ~ REQUIREMENT ., <br />_.; I. _ ~ .~. _ .. C <br />~ SAMPLE ~ ~ ~ ~ ~ ~ r ., ~~ <br />.-i. ~- .~ MEASUREMENT <br />_ .. .. PERMIT '. `: :~ _ <br />f • i_ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMfi <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMfi <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Certify under penazry of law maz this document end ell atlachments were TELEPHONE DATE <br /> prepared under my tlireNon or supervision in accordance with a system tlesigne0 ~ <br />- ' 1_'t ~, r <br />' W assure tlwl qualifietl personnel properly gather antl emluate the inlonnetion - ~ ~ y'i ~ • ~ ~ <br />" <br />~ ' • submitted. Based on my Inquiry of me person or pereons who menage me system, ~ r ,.: , ~ ! r 1 ~ <br />t , <br /> or mme persons directly responsible fir gathering the Imormation <br />me irnoimeuon '~ ~ I ~'" I ; ^ ~ f ~ 1 <br />,; , ~ ~ - . /! , <br />submiteO ls, to the beat of my knowledge end beliel, we, accurate, end complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED lam aware mat there era significant penaltlas for submimng false information, <br />Includin me ossibili of fine antl im dsonmem ror knowin Notations. OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachmen(s here) <br />EPA Form 3326T (REV 3/99) Previous editions may be tfsed.~ - ~ ~ ~ ~ THIS IS A 4-PART FORM PAGE OF <br />