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PERMITTEE NAME(ADDRESS (lndude Faci(iry NameJLocadon iJOifferem)
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<br />NATIONAL POLLUTANT DISCHARGE EIJMINATION SVSTEM (NPOES) Form Approved.
<br />DISCHARGE MONITORING REPORT (OMR/ OMB ND. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER (~ ; )
<br />MONITORING PERIOD - "( ~ ~ ~~ ` -~-'~•~ -~(• ~' •~ ^~~`•''
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~t i '~~ ~ TO '` ~ ,'. 1 ).~ ._. ~ (.: =~~. -. l ~:, ., x ~: :::
<br />NOTE: ~ Read Instructions before~m(pleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FAEOUENC SAMPLE
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<br /> MEASUREMENT
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<br />_ ':) , .; PERMIT is is F' Ok T '.;$$ " 'H°(r- ~ # , :- ~)0?R#t11O~': ~. r"••~! : " 1b1:'. ~ ^„` ~,' .'~ )I~A R
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<br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICEfl ICenify under panaNy of law thanhis document and an attachments ware
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<br />ifi SIGNATURE OF PRINCIPAL EXECUTIVE ~
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<br />TYPED OR PRINTED mitting
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<br />includi the ssibiti of fine and lm risonmaM for knowin violations. OFFICER OR AUTHORIZED AGENT
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<br />NUMBER
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<br />COMMENTS ANU EXPLANATION OF ANY VIOLATIONS (Reference all attaCnmen(5 Here) ,
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<br />EPA Form 3920.1 (REV 3 9) ` re'vtous editions`may be used. THIS IS A 4PART FORM PAGE OF
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