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PERMITTEE NAME/ADDRESS pnchde Faell[ry xamr/focaNOn IJiNBenarq
<br />NAME
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<br />FACILITY ` • R I ~I -:) t! i ~ i ~,
<br />LOCATION
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<br />NATIONAL POLLIfTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 'I~ TO ~:i :P 3'.•
<br />Form Approved.
<br />OMB No. 2040-0004
<br />r. p.
<br />NOTE: Read Instructions befor completing this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX OF TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER ICediry untlar panelry of law true Nis tlocument and ell ettachmaras were TELEPHONE DATE
<br /> praperatl untlar my tlireclion or supervision in accortlence with a system tlesignetl
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<br />W. Cordon Peters beseurelhetquall0etlpereonnelpropadygelherentlevaluetethelnbmution
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<br /> submittetl ls,to the best of my krwwletlge and ballet, true, ecwrete, entl mmplate. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />TYPED OR PRINTED lam aware that there era signlacerlt penelaes for submitting rake inbrmeaon,
<br />Innutll tna Ibili of ana and lm risonmant br knowin Nolatione. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
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<br />EPA Form 332 t 7 9) revlous Ions may ~ usetl. ~ `~ ~ ~ ~
<br />.. 003
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