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PERMITTEE NAME/ADDRESS Rnclude Facilirv NamdLOCariun i/D~e~enr)
<br />NAME ~r, {i_ .'.')II :I !'4 EMS 'rJ~,
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<br />ADDRESS {~ , ; -. ...:, ; ,; , ; ,y ;
<br />FACILITY
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMA) OM8 NO. 204f}0004
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<br />PERMIT NUMBER DISCHARGE NUMBER _
<br />' ' MONITORING PERIOD ~ ~ ' _ ~- .. ; i ,.r ", j -; ;; 5 '~ i i ,q _• '
<br />YEAR MO DAY YEAR MO DAY
<br />FROM != 'r ~:t TO it - '. ~ .~~`,+~; ;" ~~->%
<br />NOTE: Reatl Instructions before., omplefing this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. PREOUENC SAMPLE
<br /> EX OF TYPE
<br />PARAMETER YSfS
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS "
<br /> SAMPLE ~ ~' ~ ~ - ~ ` ( 1 ~ )
<br /> MEASUREMENT
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<br />i ~. ~ 'S :; r c L SAMPLE ~ = .. ... ,- . : ;=+(:4v - ( i : )
<br />(A=: f~~) MEASUREMENT
<br />. la', 1 U U PERMIT Prt i«rs ~~#tr*C#6 ... #tX# ##- 3.5 7.4 "';:: -' ;&9t. ~.,
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<br />,ti 1 L ., rl PERMIT RBPOt2T REPORT fi9rgct:#b a?tr+~###'- : fir#~s+,<::r: .`
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<br />~L'i[;~1 ;.~).,.~. 'J3E,11c REQUIREMENT 3OUA AV; DAILY }9X ~,-r' ... a f - r--; .._
<br />LiI`.;= P 7:'-,. SAMPLE .:. ' ... . e. .. .. ( 19)
<br />,,, _; L': ~; -. MEASUREMENT
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<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I Ceniry untler penelry of law that this document and aM anachments were TELEPHONE DATE
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<br />J ~ O ~ ~(/Q/ti 5 [' ~`-' preparetl under my tlirenion or supervision In azcortlance wnh a system tlesignetl
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<br />wbmittetl is , to the best of my MnaMetlge and bana SIGNATURE OF PRINCIPAL EXECUTIVE '
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<br />TYPED OR-I=RINTED lam aware that there are sign~can[penalnes for submithnp lalse inbrmason•
<br />n,cluyin the sdn mLne and lm nwnmaM br knowin violatipns OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OH ANY VIULA I TUNS (neterence au a[[acnmenls here)
<br />EPA Form 3320-1 (REV 3199) Previous editions may be usetl.
<br />T IS IS A 4PART FORM PAGE OF
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