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PERMITTEE NAMEfAODRESS rlndude 1'oeility :~'ame'!llcatiurl if UifJerrnel <br />NAME <br />ADDRESS <br />;~ <br />FACILITY <br />LOCATION ; ~ <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 />OFAB No. 2040-0001 <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER { rrrtiq under pa•null+ of law Ihul Ihi+d.wumenl mM all allachmrnl+ na•ra' <br />ared under m+ Aireclion or at <br />Irn lion in a<cnrduncr with a <br />Nem dniknrd <br />re _ TELEPHONE DATE <br /> @ <br />p <br />p <br />{ <br /> 1.. n~cun• Ihnl qualified prnonmi pny>t•rh yat her and e+aluulr Ihr infurmullnn <br /> +IIlImlllell. Ifx+fd on nla Itlyain .d Ihr pcnon ..f q~n..m .+ho manayr Ihr w++Irm. <br />ur IhrKr penon.+direcll~ n•+p rn•ihlr for I;:u hrrine Ibr informuliun, Ihr inhtrmulion ' <br />• <br /> aUhmlllyd ~r+. ID IhC IH'+1 U( ny Anow lyd¢e and In•licf. Iron, accurate. and complete. <br /> <br />1 <br />w <br />Ih <br />t Ih <br />m <br />lti <br />f <br />illi <br />• i <br />f <br />r <br />lHm <br />i <br />if <br />h <br />f <br />l SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> nm u <br />urv <br />rre are + <br />gn <br />icu <br />Irena <br />nr +u <br />m <br />ne <br />a <br />n <br />n <br />ma <br />, <br />a <br />e+ <br />a <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />TYPED OR PRINTED Inclrldin¢Ihep.++ihilil~IdRm•undimpriaonmenlfarL.nrreinR+i.dalinna. ( <br />, NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA Form 3320-t IRev 3/991 Previous editions may be used This is a =k-{part fOnn. PAGE OF <br />