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PERMITTEE NAME/ADDRESS pnclude Facility Name/Lomtian ijDij(ercnq
<br />NAME
<br />ADDRESS-; . ~ :: y ; _, ; ~ ~ _
<br />FACILITY :~ , .• . L ? >_ ; 1
<br />LOCATION .
<br />i.i 'cFF ,~~.:
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES7
<br />DISCHARGE MONITORING REPORT (OMR)
<br />.. ~.., ,, ~.,,~~I ,.
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~'i -~L TO .l '~
<br />Form Approved.
<br />OMB No. 2040-0004
<br />(~-„ -:.)
<br />_11 .: ~?
<br />NOTE: Read Instructions before `co`mpleting this form.
<br />V
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX OF TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aw'Ltis/s
<br />Lf'tS, :_"~L SAMPLE .. .., .•. .. •. ( 14)
<br />. -~ .i .: U J s D MEASUREMENT
<br />J'-'`' ~ ') PERMIT ##~°'~. ~#`~'~`'~"~ ~"~'~'~~`# 12£PDRT OPTit~NBL", ,;
<br />': TRLY
<br />!':' It JS'; VALU.
<br />.. REQUIREMENT 3::::. R?R AV;, "7 ~" ~S" h;;/'. +
<br />. _ . y
<br />_ .) L : ,~ i .., , SAMPLE .... "a:~ :T :r eY r: ~ : 3)
<br />" ~ . , ,. MEASUREMENT
<br />/ I '', i i PERMIT `#+X+G 01 s~Q1 ~. ~:91~A>P# # 7"~ : ~`:'
<br />" ~~~~-;`~. +1000.." .,~ / H~."~~:. '~l
<br />."' ~'.. T ...'7 ]:i 'J °t L_lt REQUIREMENT . 3419 A.YG~:2 i'IY7 G20 lUC 'L
<br />-t.. 4 ~ .'?r:ASr SAMPLE .. ..:e ~ .;ay :r:;. ~~: ~- ~:;: y'.:.. ...
<br />Y ~ ~ y L MEASUREMENT
<br />- ~ 1 .) ;? PERMIT. ###Ot''drk 0 i.`_.=1 #L4At~u4 :tO0r33#:.,;. •.s'8"~tfr~S>xgN}~,. >,~k't ~ ;:j"$(lf.
<br />' :. {r. +)S J!l ;, l!c REQUIREMENT jyST M$X ?, f.="' " C:
<br /> . .
<br />.r
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT ~ ~ ~ ~ - ~;p r' t.>=-
<br /> REQUIREMENT ~ ~~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT °-~')
<br />~
<br />~
<br /> REQUIREMENT ~ ~
<br />"-' ,
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT •.; ..,~ t i-,
<br />"" .. ~ ,r c, _..
<br />- "~ _. ._ ~ ...
<br />~ ,
<br />a hne "
<br /> REQUIREMENT
<br /> %r~
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT "
<br /> REQUIREMENT ~ - - - - _ --' .- - -- - - - - - - -~
<br />" - ~~ -•
<br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER ICenity untler penalty of law Nat this tlocument antl all attachmenla were TELEPHONE DATE
<br />,y l ~ 1
<br />~ (O/! , , ~ [A !! ; ~ C •"/ preparetl untler my tlsenion or supennsicn in accortlance vnlh a system tlesigned
<br />to assure that qualifetl personnel propetly gather antl evaluate the inlormation
<br /> submitletl. Basetl on my inquiry of Ne person or persons who manage the system, j
<br /> or those persons tlimL111y responsible for gathering Ina inlormation
<br />the in/onnation
<br />C , 7 ~. ~{_7(-' ,
<br />submittetl'u,to the best of my knawtetlge antl belief. we, accurate, antl complete. SIGNATURE OF PRINCIPAL EXECUTIVE 7~ ~7S ~?~~ OJ ~~
<br />
<br />TYPEIYOR PRINTED I am aware shat there ere significant peruJties for submitting lake inlormation,
<br />inclutlin Ne ossibili of fine antl im risonmem for knows violations OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />UUMMhNfB ANU tXF'LANAl1UN Oh ANY VIOLATIONS (HererenCe ell aftaChmenrS here)
<br />.L c'A5' '~],til'r .. -.. ..~.,. ~ ~ yr, 'LY ..4 '. 'LT .' „" __ ,y< _. -,
<br />_. -i. ~~ :ti7.
<br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. THIS IS A 4-PART FORM PAGE OF
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