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PERMITTEE NAMEIADDRE$$ (/nchrde £aci!lry NamNLocadon lJDlfferen() NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME _ - DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS . :6 ... , - , _. <br />~- e , ~ ~ _+ PERMIT NUMBER DISOHARGE NUMBER ~. _ <br />Form Approved. <br />OMB No. 2040-0004 <br />FACILITY ~ ~ MONITORING PERIOD ~ ~ -- . - <br />LOCATION YEAR MO DAY YEAR MO DAY ~ <br />FROM - _ TO . ~. I ~ ~ i-.' . <br />r ~ NOTE: Readlnstructions before'C6mpleting this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX oP TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS a`''v-CIS <br /> SAMPLE ' <br /> MEASUREMENT <br />.. C .; PERMIT ~ ~ .-..-, <br />,7 ~ REQUIREMENT ~ - ~ - <br />~. t ( SAMPLE - <br /> MEASUREMENT <br />~( ... J PERMIT .. ., ,,t ~,. ..~.+: ' <br />_ REQUIREMENT ~ ~ / - <br />_ -. SAMPLE - .:.. i. ... ,,, <br /> MEASUREMENT <br /> <br />~~ REQUIREMENT -~ , -. <br /> <br />_.: ~ <br />~' ~ ~ r SAMPLE ! .~ 1 ~~ ~ <br />.. <br />_ MEASUREMENT <br />~J':~,; .- PERMIT .'};F?C rlrOy. - .. - - ..- . <br />* ~ ~ - ~• REQUIREMENT ; `~ , _; - : y , <br />.. :.~ SAMPLE <br />~ ~ MEASUREMENT ~ ' <br /> <br />+ ~ L PERMIT . -. ..- .. .. c• . <br />- <br />.~ <br />~ ~ REQUIREMENT . <br />~ <br />_ _ <br />.. - - SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ _ <br />~ ~ <br />-; - - REQUIREMENT - <br />t <br />, _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER I CerVN under penalty M law that this document end all attachmanis were <br />d <br />d <br />i <br />d <br />M <br />l <br />tlh / TELEPHONE DATE <br /> <br />' <br />c. prepare <br />un <br />er my <br />rzea <br />on or supe <br />S <br />on in ecmrdance w <br />a system designed <br />to assure that <br />uehfetl <br />ereonnel <br />ro <br />erl <br />ather end <br />luat <br />th <br />l <br />m <br />l <br />e 1 r % <br />` ' <br />/, <br />1 ., <br />% <br />~ - p <br />q <br />p <br />p <br />y g <br />eva <br />e <br />e <br />n <br />o <br />w <br />on <br />i ~., <br />~ ' <br />' <br />' <br />! [/ . - ~ <br />~ ~ subm <br />tted. Based on my inquiry of Ne person or parsons who manage the system, . <br />/_ ~ , ~ <br />~! <br />~ <br />~ <br /> or those pereom directly responelble for gathering Ne Imomagon <br />the imoimaeon _ ~ <br />( // ~ /~ <br />• /~ i - <br />/ ~ • - . / ~ ' , <br />submitted is , to the best M my knowledge end belie!, true, accurate, end complete <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />'~- I ~ ~ <br />' ~ " - <br /> <br />TYPED OR PRINTED lam aware Net tltere are slgnigcanl penehles to submitting lakaintormebon' <br />includln the ossibili of tlne antl im risonmem br knowin violallons. OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAd <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLAI IVNS (hlererence all at(achmenfs het) <br />- ~ .. - .. ~ <br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. <br />s <br />-. ~ l z <br /> <br />THIS IS A 4-PART FORM PAGE OF <br />