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PERMITTEE NAME/ADDRESS iLt~luJr Furi7irc ~umr/1.a•ufion iJDifJrnnn <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />DSC G ( ) <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 />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 /> <br /> SAMPLE <br /> MEASUREMENT ' - ' <br /> <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />' <br /> MEASUREMENT <br /> r <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ` ~ <br />~"' <br />~ <br />` <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ; <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I n•niF under pa•nult~ of lua. that thi+d.rumcnt »nd »n annrhmrms ++em TELEPHONE DATE <br />prepared under m~ direction ..r +uprn i+inn in aarnrdum~r eilh u .~+trm dnil;nrl <br />to a+wre that ytwli6ad par+onm•I prnperh Yut her and ea aluatc the information <br />+ubmitted. Havd on m. inyuin of thv I»•rum ..r p.•rwm+ oho mana~,r the +a+n~m. <br />or th;w• prr+on+ dirrath rr+l»m+itrlc for gmhrnn[; Ute information, the inlurmution <br />i <br />' - <br />nuhmitlcA is, U; Ihr ha•+t of m~ Ano»letf~e uml Ix•lirf, true. ureurote, and complete. <br />SIGNAffURE OF PRINCIPAL EXECUTIVE . <br />- <br /> I »m nw»ra• that Ihrre »re +ignifwvm pen»Ities for +uhmitlin¢ f»Isr information. A <br />N R <br /> ri+nnment for 6no.riny; unluti~~rn. <br />^+ihilih ..f Rnr and im <br />l <br />di <br />th <br />i OFi~tCER OR AUTHORIZED <br />GE <br />T ODE NUMBER YEAR MO DAY <br />TYPED QR PRINTED p <br />m <br />u <br />n~ <br />e W <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments Here) <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />I HAR E MONITORING REPORT DMR <br />Previous editions me be used. Thi. t~ a -3-~~ar[ r(~rm. PAGE OF <br />EPA Form 3320-1 (Rev. 3%99) Y <br />