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--f--- <br />PERMITTEE NAME/ADDRESS ((nc(ude Fati(Iry NaneJlocnrbn lfDi$erent) <br />NAME <br />ADDRESS :~ - <br />FACILITY L <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHAAGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM - ~i TO - <br />Form Approved. <br />OMB No. 2040-0004 <br />i. `r. <br />NOTE: Read Instructions befort3 COmDletinp 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 avALrsls <br /> SAMPLE ~ ~ ~ ~ ~ <br /> <br />MEASUREMENT _ <br />' <br />}v•: ~.-,. r v PERMIT - - - - - - - - ~ -. <br /> <br />- - - ~ <br />REQUIREMENT <br />~ ~ <br />. - . _ _ _ <br />- - <br />L ~. 1 ~ - ~-' SAMPLE .. ~ ~ - <br /> MEASUREMENT ' <br />~•~'~ - 'I PERMR ~~ <br /> REQUIREMENT - <br /> <br />- ~ ~ SAMPLE .. ~ - ~ ~ .. <br /> MEASUREMENT <br />-. PERMIT - .. ~ .. <br /> REQUIREMENT <br />- ~ • . .. SAMPLE <br />~- MEASUREMENT <br /> <br /> <br />~• ~ _ REQUIREMENT <br /> SAMPLE - ~ ~ .. <br />_ -_ MEASUREMENT ~ - <br />.... , ~. .- _ PERMIT .... ~ - .. , <br />~ REQUIREMENT ~~ <br />_ SAMPLE <br /> MEASUREMENT <br /> <br />- ~ ~ - _ ~ ~ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Caddy under penalty of law that this tlowment and ell adachmam9 were ~ ~ <br />~ TELEPHONE DATE <br /> <br />` <br />` prepared under my tlirection or supervision in accordance with a synem tlesignetl - ~ <br />/ <br />~ .. _ <br />, ,~ ~ <br />- . ~ <br />' ~ • ' ~ • /~' to assure That quelRetl personnel properly gather and evaluate the intonnation <br />submitl <br />essetl <br />n <br />i <br />d <br />W th <br />h - <br />~ /~ ~~ <br />/ / <br />' <br /> e <br />. <br />o <br />rm <br />ngwry <br />e pereon or persona w <br />o menage the system, _ <br />1 I <br />- I ! I <br /> <br />or those persons olreCJy responsible for gathering Ne Imormavon <br />Ne IMOnnation <br />-ter / <br />~ <br />,r ^ <br />! <br />. <br />~ 4 <br />S <br />J <br />' <br />~ / <br />• , <br />b <br />tl I <br />t <br />b /, t) L) <br />, ~ / <br />~ , eu <br />mrtte <br />s, to <br />he Oast <br />my knowledge antl ballet, vue, accurate, entl mmplme. <br />1 SIGNATURE OF PRINCIPAL E%ECUTIVE ~- <br /> <br />' TYPED OR PRINTED am aware Nat there are signlfcam penalties for submitting false Inlormatlon, <br />inciutlin the ossibili oe ine and Im risonment br knowln violations. <br />OFFICER OR AIITRORIZED AGENT <br />NUMBER <br />YEAF) <br />MO <br />DAY <br />V V MMtN I b' ANU hXYLP.NA I I V N V t ANT V I V W I I V rvJ (FleremnCe all aR2Cnment5 here) <br />EPA Form 3320-7 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF <br />