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PERMITTEE NAME/ADDRESS pnc/ude Facility Name/rncaNOn if Di$erenQ <br />NAME <br />ADDRESS . ;, LL ~ Q • <br />FACILITY <br />LOCATION <br />. .:C <br />"., 4 <br />NATIONAL POLLUTANT DISCHARGE EDMINATION SYSTEM (NPDES) FORM ApprOVed. <br />DISCHARGE MONRORING REPORT (DMA) QMB No. 2040-0004 <br />~~_ .. , <br />PERMIT NUMBER DISCHARGE NUMBER ~ _ ' <br />MONITORING PERIOD - ~ - . ~_ <br />YEAR MO DAY YEAR MO DAY __ <br />FROM TO ~~ ~. <br />NOTE:~Read Instructions before Cdfi'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 ~~~~ <br />_. :.. SAMPLE r '; <br />~ , / <br />' <br />- MEASUREMENT ~.) ' / ~ - ~~~ ~ <br />; <br />.. _ <br />, _. <br />r••c-r i- ~ ~` PERMIT ,_ ..._... <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PEAMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMR <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICerfiy under penally pt law that this tlocument antl all attachments were <br />~ TELEPHONE DATE <br />t prepared under my direction or supervision in acwrdance with a system designed ~ ~ <br />' ~ <br />~~~~ ' ~ . <br />G'L <br />- b assure maz qualified personnel properly gather end evaluate the Intonretipn <br />i <br />b <br />d <br />B <br />d <br />I <br />f <br />h <br />h ~ <br />/ ~ ~ (~ - <br />- <br />1 ry o <br />su <br />mitte <br />. <br />ase <br />on my <br />nqu <br />t <br />e person or persons w <br />o manage the system, _ ~ <br />/ _ . - <br /> or those persons tlireNy responsible br gathering Ne Inbimason <br />Na inbrmatron • ~ ~ •~! ~ <br />I <br />~ ~ ~~- ~ 'I ) ~ : " <br />t <br />. ( r <br />/ ~ L' <br />//' <br />/ , <br />submitted is <br />rothe best of m <br />knowled <br />e antl babel <br />We <br />ac <br />r <br />t <br />nd <br />m <br />l <br />t ~ I <br />, <br />~ <br />1 <br />• <br />. <br />• <br />t ~, <br />_ y <br />, <br />g <br />, <br />, <br />p <br />cu <br />a <br />e, a <br />co <br />e <br />e. SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />TYPED OR PRINTED lam aware Nazihere era significant penalties for submitfinp tazse inbmwtion, <br />Includin the ossiblli olfine end lm risonmern for knowin vlolatlons. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />CQMMENI S AND EXYLANAI ION Ut ANY VIOLATIONS (RB/elBnCe ell at[BCnmenl5 here) <br />EPAFOrm~3320.1 (REY 3/99) Previous editlons~may be useii. ' - -- ° ~ ~ ~ ~ THIS IS A 4-PART FORM PAGE OF <br />1,, .. ~ , <br />