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PERMITTEE NAME/ADDRESS tfnrludr letilih lame/[oration if lhfftrnet <br />NAME <br />ADDRESS <br />FACILITY ~[;ay _i1'~ <br />LOCATION f' <br />ILIPJFF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. t <br />OMB No. 20x0-000a <br />i' <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. 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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT - ` <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certih under penalh of lae thal thi document and nll annchment+ssrrr <br />n <br />co <br />r <br />a <br />d <br />d <br />dim~tio <br />w <br />•n i <br />in <br />do <br />Mith <br />t <br />i <br />i <br />d <br />d ~ TELEPHONE DATE <br /> <br />r' ~ <br />1~~ i15 ~Of16S <br />Gr pr <br />p <br />rr <br />un <br />er m) <br />n <br />r <br />~ <br />a <br />n <br />n ac <br />mee <br />a c~s <br />rm <br />>;nr <br />r <br />ec <br />to a+aure that yualifird Perumnel properly yattler and esaWatr the information ~ <br />s <br />+ <br />,` ~ , _ _' _l <br />' wbmittrd. Bated iNt my in airy of the non or nuns who man <br />V fx' pr aRr thr +~ctem. ~ <br />, <br />I <br />- <br />ly7,lT" <br />1^~f"1f7TL7~L7- or those pennrtc dirral~ renlxmaible (or Ka1M~ring the infnrmuGun, lbc informaliun <br /> cuhmittrd i+. to the best td mr -rn~r Ird~e trod brlicf, tner. anuratr, and compktr. <br />` i ~ <br /> <br />1 am aearr Ihat there arc+iXnifuam penaltin for submitting (aloe Inlormation SIGNAT E OF PRINCIPAL EXECUTIVE <br />~ ~-- <br />"" ~ TYPED OR PRINTED . <br />includlnk the µnaibilit} of fine and impriwmmrntlorknowing s4daunnc. OFFI R OR AUTHORIZED AGENT AREA <br />O E NUMBER YEAR MO DAY <br />cUnnnntrv I a r+rvu tnrLratvra t tvt~ t/r AIV T YIVLA I IVIYJ irtererence an afrncnmenfs Here! <br />• '. ~ ~ ~ c iNFD. '` XEMI-~? I UN~=, F'RDr <br />EPA Form 3320-1 (Rev. 3J99) Previous editions may be used. Tills tS a -~-~atf FOI'111. <br />