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PERMITTEE NAMElADDRESS ilndudr Facility ~~'ame/Lotatiat if lhJferrnti <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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, • <br />OMB No. 2Q4D-p004 <br />Y... 'y <br />` _ !~ ,rtL <br />i'ONU t~~/47 iU lil~Y GRvt•'•"~'+MI-'A <br />~ ,% <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 /> <br /> PERMIT .. - .. _ <br /> REQUIREMENT ' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l certdy under prnalq of law that this drxvment and all attachments Mere <br />prepared nnder my dinrtion ar wlK•n isinn in accnrdanrr wiW a cpaem desiQmd <br />' TELEPHONE DATE <br /> <br />nes <br />t <br />1 <br />t <br />h <br />li6 <br />l <br />l <br />th <br />d <br />f ~ <br />- <br />S , <br />o <br />~1f1 o nccurr t <br />proper <br />esaluatr the in <br />at qua <br />.d personne <br />y ga <br />er at <br />ormation <br />suhmitted. BaseA nn rm inquiry of the person or persan+s who manage the ystrm, ~-' <br />~~ <br />~ <br />-~ -- <br /> or thwr prnom dincth n~pmsihle for Rnthvring the infartnation, the information ~ <br />:-` <br />- k <br />' <br />~ ~ - <br />\ ~j~5~9 <br />' - whmitled is, to the hest of m} Annwlydgt• and hcllrf. trite, accurate, and c-ompkte. <br />1 am aware that there are significant penalties for suhminin~ false informatkm <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />-~ _ <br />•` I .__ <br />•-~ <br />TYPED OR PRINTED • <br />including the gncibillty of fine and impris~uimrm fnr kmssing shdaiion~ OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />E YEAR MO DAY <br />I.:VMMtrv I J ArvU CAr~.nieh i rvt• yr Mtn r vtvt~ t ivte~ Inararanca an nuncnnrarns Hare/ <br />~XEMPTIDNE <br />EPA Form 3320-1 (Rev. 3'99) Previous editions may be used <br />