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PERMITTEE NAME/ADDRESS (include Facrliry Name/Locanan fOderenr) <br />NAME <br />1 ' , .1 ~ ~i l l i T i I '~ ire ... ` . <br />ADDRESS ~,1 r ~ ? Fi 1 .! "~ , 1. '~ ,; <br />i •'J / ~ .. <br />FACILITY <br />LOCATION <br />s :r: F'} 'L' <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />. .. - ;, .I 1~ .~ 1 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM ~, L ~' I TO "` ! ~ 1 <br />~~+1~ G) <br />- ':.1 ~. <br />":.4 - -~ `.. ;~ is <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />"NOTE: Read Instructions before o~ plating 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 ~a'~/$ <br />~L i'i ,. ~~H ~:4". SAMPLE ...,.. .- i .:) :.+:~Cr: '. ... .. ..... <br />J ! `, L MEASUREMENT <br />'' + ` ~' 1 .) <br />~ PERMIT +%x#04?? 0 - F': =1 44##L+:# #3###C #'2#4411 ~ '~ T96A <br />L~1"Y C~~..~~~ <br />YP. :,U: REQUIREMENT - ~ INSR Hll f[ ';')-11 ~ ~ tFi,. _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ - - -' 'x-,.; ' - - `'-'r - -- -' <br />+• - <br /> REQUIREMENT - - r <br />~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ -• - t,~pY_ ~<_'-: <br /> REQUIREMENT - <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~"'^ . <br /> REQUIREMENT ~ - ~ ~=n,-~~-~~ _ ^~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT : -~x". ' .. <br /> REQUIREMENT _ ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT `. ~ ` +; ~ ~: "~. ~. ..: ` <br />~ .... <br /> REQUIREMENT ~ ~ <br />r~ '"`~~ ~ - ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - ~ E"'~ ~ '" <br /> F ,. <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICedAy untler penalty of law shat lh~s document end en enachmems were <br />di <br />i <br />d <br />h TELEPHONE DATE <br />_ <br />n <br />~ / / <br />l < <br />i/ <br />~ <br />' <br />~ prepared under my <br />rection or supems~on <br />n accor <br />ance vm <br />a system tlesignetl <br />to assure Nat qualified personnel pmpetly gather and evaluate the information <br />1 , <br />ti <br />r <br />, <br />/ <br />7 ~, submitted. Basal on my inquiry of the person or persons vmo manage the system ~- i / ~ <br />L <br />( <br /> , <br />or those parsons directly responsible for gaNering the inlormagon <br />the Inbrmalton Q f f <br />l f <br />f - <br />1 <br />.' <br />/ , ~) ~ <br />( i <br />~ <br />, / ~ <br />, <br />1 aubmined Is, to the best al my knowledge and belies, true, accurate, end ramplete. SIGNATURE OF PRINCIPAL E%ECUTIVE ~~) <br />/ ~ 3 <br />~ ~~ - <br />TYPED OR"PRINTED I em aware that there era signiflrant penalties for submitting seise inbrmahon, OFFICER OR AUTHORIZED AGENT NUMBE YEAR MO <br /> indutlin the ssibili Wine and im risonment for knowin violations. R DAY <br />V V MMtN I J ANU tXYLANA I I V N Uh ANY V IULA I I V N5 (Hale/2nCe al/ a[CdCnmeOrS llereJ <br />._ ~ J Ali ~. ... .. ~~... i.._ - .. ~'J ~~ Oli ... i~r 'L. ~. .IL:L.. . ... r .._ .-. ~ ~ 4. CIF ~~''. - <br />i <br />-.. L. ... _'~ _ ~ F'.. ... ll ~' ?`.'i .. JIi. ,. -.. ~FF`-'i, :. '?`. .-:i ~., T_..i. ~ V. _. .. .' .. ..+.., <br />EPA~Form~3320.1 (REV 3/~9) `Pre'vious a itions may be used. THIS IS,A_4-PART FORM PAGE OF <br />