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PERMITTEE NAME/ADDRESS tlnrludr F'acilih S'umdGrration if IFfferrru~ <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />~7T111V tom: ~~J'~1 >? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONfTORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approvetl. <br />OM8 No 2040-0004 - <br />r <br />i <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I u•rtiP under penalh of lax that thi. d~xumrnt and III altachmrnh xen , "" i TELEPHONE DATE <br /> prepanvl and v m? direction ur wpar\ ision in xarrdunce xilh a +?+tem dcmyCned <br /> to aswrr that qualified pr namnrl properl\ yuthrr arerl r\ulu~tr Ihr infnrnmtirm <br /> cuhmilttYl. fta.avl on m\ inyufr? ~d the pa•r.rm nr prr+om xhu mana¢e the +?dcm. <br />ur thu+c pervwra dtrectl\ nrprm+Ihlr for katherin0 the information, the information <br />~ <br /> whmitt\d i.. In the trr.t of nn Anoxled{ee anA In•Iia•f. true. aamrute, and comptrta` SIGNATURE OF PRINCIPAL EXECUTNE "~ <br /> Inn. axarr that (here are aicniriaant pa•nalli\~s for +nhmdtink fat+r infurmutem' AREA <br /> msibilih of fine atd impri.onmem Gar Am~xinx rndallnn+ <br />the <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT ODE NUMBER YEAR MQ DAY <br />TYPED OR PRINTED . <br />p <br />ne <br />u <br />nK <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. 3.99 Prey ,.u~ •. r!,. -. • ay ~e ,•_:1 I I'u, j, .t -+ I`a!? :~~~Ir~. <br />