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PERMITTEE NAMEIADDRESS tlnduAr Far•iluc .~'omr/Lucorian iJthJJerrntl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION ,~/-,:- ~.t ~: i~ ~ 2 t,3` <br />;`! !• r11~: C), '~ F:(;;. rat"~,T ` ~)P~ MAf~IFi.ryER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <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 /> <br />•~~~ r.o u~.~;cria <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 />` <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 arnit) undrrpenwln nfluw Thal Ihi.diKUmrMwnd:Jlallnchmrnt+wrre <br />urrd under nn dirrcti.~n ur u <br />enisinn in accordance with w s+Icm desiGnrd <br />re TELEPHONE DATE <br /> p <br />p <br />p <br />^r w++un• Ihwl yualifird prrwnnrl prnprrh KatM•r uml e+uluule thr inlnrrnatinn I <br /> +uhmilled. Ru+rd nn m~ inepdn :d Ihr pav+on or pervm+ whn manage Ihr .+slem, <br />nr Ihu++• penarn+dirrcp~ ra•+tem+i Me for gathrring the infurnwtinn. the inlnrmu6un ~ _ 1 <br />'• t <br />• <br /> .uhmiltad n. hr tha• M+t of m~ Anua kdgr and M•lia•f. trua•, accurate, and cnmplrp•, 1 :. , ___~ <br /> I um aware Ihwt thtre urr siRnibc-ant penultir+for+uhmittinR false infornwuon SIGNATURE OF PRINCIPAL EXECUTIVE <br /> . <br />d <br />d <br />l <br />d OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED in <br />u <br />ltrglhrpossibi <br />it~ottinran <br />impri+anmentfnrMnowin~+iulution.. NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Previous editions ma be used. ~lts~ to 8 -~- HR 101'111. PAGE OF <br />EPA Form 3320-1 (Rev. 3/99) Y r <br />