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PERMITTEE NAMEJADDRESS rlncludr FatiGh• .Yarnr/lurnrinn iJJAfJnrnt, <br />NAME -; :=~ L~ i <br />ADDRESS ~ ~ - <br />t?c <br />i. it $ I •~ <br />FACILfTY ;~ '1 ~ ~;i3 ~ t F't <br />LOCATION ;., ~ s Z ~ <br />:y:nt~.~ waaT , ..;;,,,;~ ~I~tiA~~Ea <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <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 <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX TYPE <br /> aNALVSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , <br /> REQUIREMENT :'i ~ <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 l certili under prnultr of law ttm{ thL d~xumrnt una ull a{WChmrnU werr TELEPHONE DATE <br /> prepared under my dirrr{ion or .uµ r.i.ion fu an ordance with n >:•~stem desiFnrd <br />~ --'` <br /> to assure Thal yuall6rd pers~mnel proprrl~ g:d lx~r and e~nluatr {he informaleon - ~ - <br />_ ~___ whmillyd. 13asrd un m~' inyuirr of Ihr prnon nr peru~m who manage [hr scstrm. / <br />~- --- <br />~ nr IA~xse prnom dinY4h ra{am.lble for untherinR the informminn. the Inlorma{ioa --~ <br />_ <br />~ wl <br />ix <br />am <br />a <br />d <br />o <br />l <br />t <br />d <br />h <br />h <br />! <br />L <br />d <br />d h <br />li <br />r <br />{ ~ ~ <br />; <br />'S ~ <br />~ ~ ! I <br />- ~ ~ c+r u <br />Rr an <br />nor, a <br />ur <br />. <br />n <br />c <br />mp <br />e <br />e. <br />submitte <br />h. to t <br />r <br />m. <br />nu <br />e <br />e <br />r <br />. SIGNATURE OF PRINCIPAL EXECUTIVE _ , ,: <br />, <br />,_~ <br />. <br /> I am aware that them ~re.ignifKan{ penal{ir. for.ubmitting fake inlnrmatloa, AR <br />A <br /> <br />' t for I:nowin -i lalinns <br />{h <br />ihili{. of fi <br />id f <br />rlso <br />i <br />l <br />di <br />"' OFFICER OR AUTHORIZED AGENT p <br />NUMBER YEAR MO DAY <br />TYPEDOR <br />PRINTED . <br />r <br />ne m <br />m <br />nmrn <br />nc <br />u <br />n{; <br />~'~` p c <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference alI attachments here) <br />EPA Form 3320-t IRev. 3199) Previous ed+tiors may be used. <br />)043: Th <br />