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<br />PERMITTEE NAME/ADDRESS Unclurlr Facililf A'amdltrcation if INffnrnp <br />NAME M.i C4: t'i'~ <br />ADDRESS _. ' <br />--'~Ltil1~L~ ~~~ Q'~13 <br />FACILITY F <br />f'T;;_ <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMRJ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />t~l_+I~I~F F <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• <br /> <br />EX FREQUENCY <br />of SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~~ ,~ ~ '_{ ~! 15t_~ L <br /> MEASUREMENT <br /> PERMIT ~ ~ ! . .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />• <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certir. antler penah~ nr low mat m+. d~Kamem and au mtachmente were <br />di <br />i <br />d <br />d <br />i <br />i <br />i <br />d <br />h <br />t <br />d <br />i <br />l ,- =~% <br />- TELEPHONE DATE <br />t prepare <br />er mt <br />„u nr supen <br />on <br />n accor <br />ance wit <br />wi <br />rerl <br />~ <br />u .~+ <br />em <br />rt <br />Ppn I ~ -~ <br />~, JAS ~ `~_~ , ~y",._ , ~; <br />~'- to a,.are that yualiriid pe i~unmi proprri~ Bother and e~ahmtr tM~ infurmatMm .. ~ ' <br />~'!~" <br />~~ <br />/ <br /> whmitted. Ruud nn me Inyuin of the pcnun or Iwr.on. who munaXr Ihr .rtitem, j <br />y _~ <br />.~___ <br />_ <br />_ -_ <br /> ur thine prrvm. directly nawu.ihle for galherinR dre information. the inforniathat t_ <br />!- " <br />`-- - - ._. - ~ <br /> <br />. ~ _ _ ~`~.-- <br />' ~ - ''- <br />huhmitied i., to the halt of nn LnowledKe and Iw•Ilef. Irve, aetufatr, and romplcte <br />I am aware that th <br />lti <br />f <br />h <br />lal.r i <br />for <br />ation <br />rr <br />r <br />I <br />ifk <br />t <br />en <br />r <br />itti <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ <br />`') ''... i) ~.,' i, <br />, <br />~ <br />' ~ ~^ <br />- il,~ <br />TYPED OR PRINTED . <br />r <br />ar <br />. <br />fln <br />an <br />p <br />a <br />e. <br />o <br />.u <br />m <br />ni; <br />n <br />m <br />inelodinK for p.»nihilih of fine and impriammcm fur Anuwin>Z tiolatione, OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />GVMMtIV 15 AIVU tAYLAIVA I IUIV Vh ANT vw~F+l wrva Inererence an arracnmenrs Here/ <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. )~4J4i. This i:ti a 4-part form. <br />