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PERMITTEE NAME/ADDRESS i/nrfuEr Faciti(v.4mndGxatinn iflhfrrrenf) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No 2040-0004- <br />3B!>^ISH CAF. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ <br />' ' <br /> MEASUREMENT ~'- ~ - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />f <br />~ <br /> MEASUREMENT . <br />~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT i t <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 J r <br />~ ' <br /> MEASUREMENT - - - ~ r°~`, ~' <br />PERMIT <br />REQUIREMENT ~ Y <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I crniH ender prnaln .,flaw ww mi+e~wunrem and all ultarhmmt+were TELEPHONE DATE <br />prrpured corder m+ dirrcti.m ..r +upra+i+ion in :nt~nrdnnrr with a +~+trm dniKtlyd <br />to ~++un• Ihul quali(kd prnonnrl pnrperl+ ¢athcr and rrahwtr tlk infnrmutirm <br />arbmiucd. Na+rd on m+ inquire of lhr la•r-+.m ur pc n.ar. r+ho mnnuRr the +~+Irm, + <br />or Ih..+e penun+dirrclh rr+pm+ihle (or gwl herin>; Ihr inG~rmalirm. lhr infor minion --} <br />auhmillal i+. to Ihr hr+t .•f m~ kruiwlrA;te cord Irrlp•f. tnrr. aerurrtr. and eomfJrtr. <br />SIGNq'TURE OF PRINCIPAL EXECUTIVE <br />~ 1 ~ _. <br /> <br />~ <br /> <br />TYPED OR PRINTED rnutloa <br />I am .r rrarr That Ihrrr an siytnincanl prnallia•+ for +rrbmil ling faly hd~n <br />includinK the ihiliq .d rinr and im ri+onmrnl for Lnoh in • i Inu.a„. <br />w^+ P s."' OF~ICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments Here) <br />EPA Form 3320.1 IRev. 3'99) Previous editions may be used ~ TI11ti i~' S •~-flaTt'fnfltl. PAG <br />