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PERMITTEE NAMElADDRESS ilnrludr FaciL'h.\'amr/l~rntinn iflhffrrrnri <br />NAME <br />~ ADDRESS <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D RJ <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> MEASUREMENT <br /> PERMIT ' '~'"~ ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ~ +°•til' °nA+~ I~romt..d la~~ that thi+Aucument amt all atmehment.were <br />rr <br />rrA undue m <br />dinetioo or c <br />rrricion in wcurdnnre with <br />uc <br />d <br />+i <br />d TELEPHONE DATE <br /> p <br />~ <br />~ <br />up <br />a ry <br />m <br />e <br />ym <br /> lu axwrr that yualifi~d penunnrl prwprrt~ gnihrr and r+uluate Ihr information <br /> +uhmi11..1. baud im nq inyuir~ u( the prewar nr prrwm+ wM~ manupr IM• .~-Nrm, <br /> ur th~nr prnun+dirt•rtll rr+fa~mihlr fur KatMrinK the in(urmati.m. Ihr information <br /> +uhmillyd i+, to the Iwwl u(m~ 6wowladka and hrlir4 Inte, x'avr~tr, and rnmpktr. <br />1 am nwarr that there nee sit;nifirant prnaltie.+ for+uhmittinK fal+r infurmatiua <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED itad~alirtg Ihr prts+ihililr of fine and imprimnmrnt fwr -nuwin>Z.i~datiom. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />ODE YEAR MO DAY <br />GUMMtN15 AIVU tAYL/+tvAtrl/rv yr AIYT VIVLAlIV1VJ Inererence an arracnmenrs Here/ <br />EPA Form 3320-t (Rev. 3~) Pfevious <br />U~ Thiti is a 4-part farm. <br />