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PERMITTEE NAME/ADDRESS pncluJe Farili(v NamelLocanon iJDif(errnq
<br />NAME
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<br />FACILITY ~ ~ -
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NRDES7 FOrm Approved.
<br />DISCHARGE MONITORING REPORT (OMR) OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER _ ~ , r ,-
<br />MONITORING PERIOD ~ " ~ - .. - •~ i ° `' t _ P L ?. 'i i'
<br />YEAR MO DAY YEAR MO DAY _
<br />FROM ) . ' 1 TO ,; ! , ~ 7 i :... ~ ,.:. _, :..r
<br />NOTE: Read Instructions beto a completing this form.
<br /> QUANTITY OR LOADING pUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~/s
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<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CertAy under perulry of law that this document antl all attarhmenls were TELEPHONE DATE
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<br />/ f prepared under my direcGOn or supervision In accordance with a system designed
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<br />= ' ~ r' / tc assure that qualified personnel properly gather and evaluate lho inlorma4on
<br />submitted
<br />eased on my Inquiry of the person or parsons who manage the system _
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<br />or those persons tlrtedly responslblo for gathering the Inkrrnalion. the iMOrmation -
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<br />e. SIGNATURE OF PRINCIPAL EXECUTIVE C ~ . eri ] ]
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<br />TYPED PRINTED I am aware that Nera ere sign~canl penalties br submiding lake Inbrmation,
<br />includi Iha slbil of Gne and 1.n risonment br Mnowin vloiations.
<br />OFFCER OR AUTHORIZED AGENT
<br />A
<br />NUMBER
<br />YEAR
<br />MO '~
<br />DAY
<br />,.vrv~iv~u.io.vw ~nr v,rvnivn yr nwr vivv,nvrvo lncroreuue au auaunnerns acre/
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<br />EPA Form 3320.1 (REV 3199) Previous editions may be used. . , ~ • THIS IS A 4-PART FORM PAGE OF
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