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PERMITTEE NAME/ADDRESS Qndrrde Faeiliry Name/LOrvnon ijDifferert) <br />NAME <br />ADDRESS ~ .. ~ T ' <br />FACIUrY , <br />LOCATION <br />.. is - <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <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 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 ~~~ <br />- ~ , ~ ~ SAMPLE <br />MEAS ~ ~ ~ <br />`~ <br />~ <br />~ ~ ~ <br />~ ~ - <br />- ~ <br />% ,/~ u <br />~/` <br /> UREMENT // .) i <br />.,~ i~-- ,. .. PERMIT - _ _._- - , ~ - .. <br /> REQUIREMENT .. <br />. , . SAMPLE ~ ~ ~ ~ / - ~ ~ , <br /> MEASUREMENT \. / ~~~~' <br /> , ~ <br />t .- PERMR ~ ~ ~ ~ - <br />- ~ ~ ~ ~ , L. REQUIREMENT <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Cedrty under penalty of law Ihaz Ihis tloctiment and ell attachmenUwere / TELEPHONE DATE <br />_ <br />' pmparetl under my diredlon or supervision in ecoortlance rnth a rystem Designed _ ~ <br />. <br />/ r tc assure that qualified personnel properly gather antl eraluaze the irrlormalion L <br />_. <br />• / <br />(~. ~r / / _ J /~ / • ~ eubmaleD. Bored on my inquiry of Ne pereon or persons wtq manage the rystem, - <br />r <br />/ - ~ ~ <br />~ ~ <br /> <br />/1 // <br />or those persons directly responsible br gathering Ne inbmiaflon <br />the IMOnnatlon __ _ <br />/ <br />/ <br />~ • ~ i <br />' ~ <br />- <br />- ^ <br />/ <br />/r,' <br />' r <br />- ~ , <br />to the best of m <br />submRted is <br />knowled <br />e antl beliel <br />true <br />ac <br />t <br />tl <br />l <br />t i _ <br />/ <br />/ / r~ / ~ <br />, <br />r , . .. , <br />r ~ - _ - , <br />y <br />, <br />g <br />, <br />cura <br />e, en <br />comp <br />e <br />e. SIGNATURE OF PRINCIPAL EXECUTIVE " : ~ / I ' - <br /> <br />TYPED OR PRINTED I em aware that Here ere slgnlfram penalties for submMing lake Inbrmetion, <br />Includ~n the ssibil' of nne and lm risonmern for knowi vioiasons. <br />OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />V V MMCIY 1 J HIY V CAf VUYH I IV ry V f HIY r v i V w I I V IYa Ineroronce en auacnments nera/ <br />EPA Form 332x1 (REV 3/99) Previous editiohs may tie used. - ~ THIS IS A 4-PART FORM PAGE OF <br />