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PERMITTEE NAME/ADDRESS (Inclode Facility Name/Locanon i/DBcrrnq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMRJ OMB NO. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER _ • i ., 1 i _ t
<br />MONITORING PERIOD ~ "- 1 D I 1"' 4' Tr"~ is
<br />YEAR MO DAY YEAR MO DAY
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<br />NOTE: Read Instructions beforeplating this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FflEOUENC SAMPLE
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<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~'a-ti51S
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<br /> MEASUREMENT
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<br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I Grtiry under penalty of law That Nis document end all anachmems were TELEPHONE DATE
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<br />J ~ G : / ~~~~LM19 ~ ~Cl~~ prepared under my direcvon or superWS~on in accordance wnh a system tlesignatl
<br />to assure that qualified personnel properly gather antl evaluate the inlormafion
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<br />subminetl is, to the best of my know SIGNATURE OF PRINCIPAL EXECUTIVE 1- ~ t '
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<br />TYPED OR PRfNTED I am aware mat there era significant penalLea for submitting lake inlormahon'
<br />intlutlin the ossib~li of fine antl im risonment for krowin violations. OFFICER OR AUTHORIZED AGENT
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<br />NUMBER
<br />YEAR
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<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
<br />EPA Form 3320-1 (REV 3/99) Previous editions may be used.
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<br />THIS IS A 4-PART FORM PAGE OF
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