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PERMITTEE NAMElADORESS tlncladr F'utilift \bmr/!oration iJl>;/jrrrnJl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />I`1R~~lAG)=[•i <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 />OMB No 2040-0004 - <br />Ff?AL1i~.~LF CI <br />%, <br />NOTE: Read Instructions befor~completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREDUENCY <br />OF SAMPLE <br /> EX 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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I errtit.:mM-r Iw•nauy atm~ that thisd~KUnx•m and au:uu+-hm~nn M+•r+- TELEPHONE DATE <br /> prepurrd undrr nn direction ar •npe vision in arcordansr with a system d+-signrd <br /> to assure thrl yualifird prrwnnd prnprrN gnlhrr n+e1 rvalualr Iho infurmatia+ r • <br /> .uhmitleA. itaud ~m my myuin +d thr person ..r prnons Nho m:muge the sy ~trm. <br /> ..r thine pavans dinvily n•.prosiblr far guthrring Ih.• information, the inlarmwiun <br /> We tr++t .d m <br />nwlyd <br />r and I+rlief <br />tray <br />accurotr <br />and cam <br />letr <br />h <br />iu <br />d is <br />u <br />k ~ I <br />_ <br /> p <br />. <br />, <br />, <br />. <br />su <br />m <br />+ <br />, <br />. <br />y <br />n <br />g SIGNATURE OF PRINCIPAL EXECUTIVE i <br /> I am aware that there ore significant prnalti+~ for .uhmitung false information. <br />h <br />m f <br />wi <br />~ <br />d <br />ti <br />n <br />l <br />f f <br />J i <br />i <br />A OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />TYPED OR PRINTED uy o <br />s~a+mr <br />or <br />nn <br />n_ <br />n <br />s. <br />including thr pnci <br />i <br />inean <br />mpr <br />a <br />a <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all <br />here) <br />EPA Form 3320-t (Rev. 3r'99) Previous editions may be used. ~!J 1 b~ / C,T11i~ t!. e -~-(~1tt fOfm. <br />