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PERMITTEE NAME/ADDRESS rlnc(udr I•'aciGty J"amdLocation iJ/hJfrrrat~ <br />NAME <br />ADDRESS ~ 1 • <br />FACILITY <br />LOCATION <br />C•U ~Tf~3 <br />~faf`dAGE~Z <br />NATFONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMRJ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />rlir <br />~~ <br />~' <br />Form Approved. <br />OM8 No. 2040-~OOd <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT ~~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~i <br /> MEASUREMENT ~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~ <br />"' ' <br /> MEASUREMENT I ~ ~~- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ' <br /> \, <br />' <br /> MEASUREMENT ~ <br />l + - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE I <br /> MEASUREMENT <br /> PERMIT .. ._ <br /> REQUIREMENT ~ , ; <br /> SAMPLE ~ I <br /> <br />MEASUREMENT <br />~ t <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT ' <br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER 1 ~r'r Ids °mtrr pe•nxu~ of Ine urxl mh doaumem end x11 nnxclunrow Heer <br />rr <br />arrd under m. direcUnn or w <br />r~i <br />{ <br />n m rrr <br />rdu <br />with <br />H <br />A <br />i <br />d TELEPHONE DATE <br /> p <br />p <br />pr <br />. <br />n <br />o <br />nce <br />u ~~ <br />rm <br />ec <br />gne <br /> ur u++un• 16x1 ymdifirA prnramrl pniprri~ Kalhrr and ea xluxlr the informalirm <br /> whmiUed. 6axd on m. inyuin o(Ih.• prr.on nr IH, r.rms who mm~nKe lin~ yslrm. <br /> or IMr.a• pa•nons direa-Ih re+ponsrhk for gxtherin>; the mhrcm:rtiun. Ihr in(ormulion <br /> adrmillyd i.. In Iha• M•.1 n(m. knout ledge :urd M•lief. Inu•. nrrurair, xnd romplrlr- <br />I :un .nrxrr Ihut there xrr si>;nifiram Ix•nahir. for+uhmiuinY fuly iMormmi„n -/ <br />SIGryATURE OF PRINCIPAL EXECUTIVE ~ <br />TYPED OR PRINTED • <br />nuludury Ihr Inr..ihilih n(finr and impri+uament (or knorrin>: rirrlalium• FFICER OR AUTHORIZED AGENT ARLA NUMBER <br />CODE YEAR MQ DAY <br />Vvmmuvra hl\V cnr ~ru ••+rrvr. v. .•.r.. .rvv.rrvrw Irrcrcr cnr.c on ac mr./In/cluJ rlcl c/ <br />EPA Form 3320-1 (Rev. 3/991 Previous editions may be used. `Thi, 1s a •~-part I•ofnt. <br />