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PERMITTEE NAMFJADDRESS flncladr Facititr.Vamr/location iJlhfJrrmt) <br />NAME ~ ,,} ~ ~_ <br />ADDRESS ~. _' ~ ~ r i L i ~ t_ <br />>3~x ens .. <br />~ p ~ C [J 81 <br />FACILITY 't-iOFt I ZEN I'`f I I~I'r <br />LOCATION 1_z~ ~ O ~ 1 <br />t wntrC I.tAr1G. MTAIf= M~tUAGFR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approvetl. <br />OMB No. 2040-0004 <br />SR°~MINE TRNG TRILi TO 7tJTTLS D <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX NA~vsls TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />;~ ., SAMPLE <br /> MEASUREMENT <br /> , <br />- <br />- <br /> PERMIT ~1.f~i.:faT f~~-;Ji , <br />,. <br /> REQUIREMENT `•:~^R /-+VL_ t7:~IL'° • <br /> <br /> SAMPLE <br /> MEASUREMENTI <br />. l T KtF'Lr? <br /> PERMIT ' <br />- <br />_ REQUIREMENT ~J6 TIt~ I L <br />J <br />. <br /> SAMPLE <br />~-r~: MEASUREMENT <br />` <br />_ PERMIT - ,~ :~~ . -. <br /> REQUIREMENT ~ • ' r;'i~ ~ '~i;; <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. _-..-... -;T ~ .r~r _ <br /> REQUIREMENT ` T j' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMEJTtTLE PRINCIPAL EXECUTIVE OFFICER I crrtif~ undrr petwU~ of Ia» that lhi+dINLOMnI and all atwchmrnd »ere TELEPHONE DATE <br /> preparrd undrr my dirraaiun ur +upcr+ision in unordnncr »ith a sv+trm dnigtxd _ - _ _T,_ <br /> In u+wre that yuulified pemmnai Pruprrl> gatbrr and rvaluatr the information <br />' <br />-- - submitlyd. Roscd nn tm inyuin' a( thr yenun or {x•rwm+ »ho manage the s~+irm. + <br />~ <br />_ _~ <br />_ <br />" ~ oasiblr for gathrrinK Ibe information. Ihr information <br />n <br />+ dit <br />rth rc+ <br />h -' - - <br />, <br />- P <br />csc pen <br />n <br />e <br />or t ~ ! <br />• , • <br />~ ~ - <br /> wbmitt d i+. to thr heM of m~ km~»~Ird~r and bdieL trot. aaruretr, and comgrtr. SIGNATURE OP PRINCIPAL EXECUTIVE -• <br />' ~ <br />`"" 1 am a» are Ihal tMrr rn signi(lcam penaltir+ fur wbmittinR folae informatioa. <br />THORIZED AGENT <br />R <br />ARE <br />D <br />TYPED OR PRINTED itKludinK the po++ibilit~ of fmr and impriwnnnent for t.no»irtK sMlation+. OFFICE <br />OR AU DE NUMBER YEAR MO AY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference alt arracnmenrs Here/ <br />EPA Form 3320-1 (Rev. 3199) Previous editans may be <br />PAGE OF <br />..' :This is:a'4-past 1orn~. <br />