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PERMITTEE NAME/ADDRESS,fnc(adrf'ariGtv,Yamr/Lotu6onifDif/rrenn <br />NAME <br />ADDRESS - -- <br />E3 <br />FACILITY ~ I~I;r X '~' ~;,{ h. i I !". <br />LOCATION `_A' ~_ J C L <br />i onlrf= r;~Ail>' • :~~ T til` i'rtAWA{,ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMA) <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 />Q ~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIs SAMPLE <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT • <br /> - -.._,~ <br />- _ , <br /> PERMIT <br />REQUIREMENT x<: ~ :~~~ fiLi'D~i <br />TI'4~-T I'lii%~ . .. <br />_, rr _ <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 /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />RINCIPAL EXECUTIVE OFFICER { rertif) wider penalq e(InN thnl thisdiwvment and all atnuhment+NfR TELEPHONE DATE <br />NAME/TITLE P prepared under m. Airrctiun or mpeni+iun fn wcordanar with a ++s(rm designed - <br /> <br />_ _ .- .- --- --- to as+ure that yuelified prrxrnnel pnrperls [tether and e+uluate tIN• infurmathm <br />+uhmillyd. Bawd un me inquire of the person nr persons NMr manage llu s}stem. <br />the in(nrntatioa <br />nmihle for gathering the inGrrmatiun <br />cth res <br />th <br />• <br />o <br />s di J <br />- -1 "'- <br />/ } <br />f -` " --' - _ <br /> <br />- <br /> <br />, <br />- . <br />p <br />ou {N <br />n <br />n <br />re <br />or <br />submitted i+, nr the IN•d of m~ kneNkdgr and hellef, true, accurate. and cnmpkte. <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~ • - ~ ~ ~ J ~ <br />( <br />• <br />- ~ <br />• I am aNarr that there are signira•anl pennltirs (or submitting (ul+e in(ormati+m. THORIZED AGENT <br />R <br />R AREA <br />BER <br />YEAR <br />MO <br />DAY <br />R PRINTED <br />TYPED includin0 the poxsibillh of rinr rend impriurnment fur knowing riolation~ OFFICE <br />O <br />AU NUM <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Aelerence all attachments here) <br />-; <br />FPA Form 3320-t iRev 3991 Previous editions may !x used. <br />Tftis IS "a 4-pari tOrnl. PAGE OF <br />