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PERMITTEE NAME/ADDRESS (Inclkde Fanliry NamelLocaNon i/Dij(e.ent) <br />NAME _ <br />ADDRESS - u~--~- -- n' ~-~- <br />- ~ .. _T . <br />FACiuTV : -' <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMRJ <br />PERMIT NUMBER DISCHARGE NUMBER ~ _ <br />Form Approved. <br />OMB No. 2040-0004 <br />MONITORING PERIOD - ~ ~ - ~- - ~ . .. <br />YEAR MO DAY YEAR MO DAY <br />FROM ~ TO ~ ~ ~ ~ -,' ~ ~ ~ ~ .~ <br />NOTE: Read Instructions bef6fe~CIOTnpleling 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 ~'V-~/s <br /> SAMPLE ~ ~ ~ ~ ". ~ <br /> MEASUREMENT <br />. - ~v - PERMIT - ' ~" "- ~ ~' - ~ • <br />- ~ REQUIREMENT ~ ; - - <br />_ . SAMPLE i! <br /> MEASUREMENT <br />t ~ PERMIT ... ~ ^.:, ~_.. <br />' ~ - I REQUIREMENT - <br />_ . , ~ ~ ~ SAMPLE <br />., ~~ ~ ~ MEASUREMENT <br />C . _ J .. PERMIT ., ~ ~ ~ .. .. - . <br />•I REQUIREMENT <br />- ~'- ~ , SAMPLE <br />- MEASUREMENT <br />i : . - . PERMR .... :y : :;: ~;. ~ ~ - - ~ .. .. - <br /> REQUIREMENT - <br />- -. SAMPLE ~ - ~~ <br /> MEASUREMENT <br />,. PERMIT <br />~ : ~ ~ AEQUIREMENT - ~~ _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICertiy under penalty of law that this document and all anachmente were <br />dir <br />d <br />d <br />ti <br />i <br />i <br />i <br />nN <br />d <br />t <br />d <br />i <br />d / <br />' TELEPHONE DATE <br /> prepare <br />un <br />er my <br />ec <br />on or superv <br />on <br />n accor <br />ance v <br />a sys <br />gne <br />s <br />em <br />es ~ <br />__ _ _ ~ <br />_ _ __ <br />~ <br />, <br />./i W azsure that qualified personnel properly gelher and evaluate tba IrAOrmatlon <br />eubmRied <br />Based on my mqun/ N Ne parson w pereom who mena <br />e the s <br />stem / r <br />( <br />/ . J <br />~ -/ ' <br />-" <br />! <br />Z <br />i <br />r <br />_i <br />' - . <br />g <br />y <br />, <br />w those perecm directly responsible for gathetlng Ne Information <br />Ne Inbnnetlon / / <br />. ., _ _- <br />~ ~- /.. <br />I `~ I / L <br />~ <br />~i , i <br />f ~ ~ <br />( J <br />(~ <br />• i - subminetl Is , to tho best of my knowledge end belief, true, accurate, end complete. <br />I <br />h <br />i <br />fi <br />f <br />i <br />h <br />i <br />rl SIGNATURE OF PRINCIPAL EXECUTIVE i <br />TYPED OR PRINTED <br />~ ~ r em aware t <br />el Nare ere e <br />gn <br />rant penalt <br />es <br />or sul~n <br />t <br />ng <br />alse Intimation, <br />Inclutlin the osslbili of fine ens i risonmerv for krovri oblations. <br />OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here) <br />. ~ - ~ ~ _ . . <br />.. .. ._ .. .. _ ... o :_ <br />EPA Form 332b1 (REV 3/99) Previous editions may be used. ~ THIS IS A 4-PART FORM PAGE OF <br />