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PERMITTEE NAME/ADDRESS ~InrJrrde Paet7ig Abmei[ixutinn if tb%J'erenq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION ,•r-: r -~ ~ _~ <br />~,-~rr; <br />~~O r:.1S34 <br />MAP~~6ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <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 />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 /> 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 ~ rnif~ under {xnalh of law that Ihi. dikuntrnl and all au:aehmrm` wrrc <br />rrpureA under ma AirarYi~m ur wpen I~iun in accuniattcr with a .~ atem deai>:ned TELEPHONE DATE <br /> p <br />to a.~urc that quahfiavl Ixrvmnrl prgxrl~ gather and ra aluau• the infunn:diun <br /> wbmiuad. Ftuvd on m~ inyuin ..f tho pa•rwn ..r prrum. who managa• thr .)acm. <br />~ <br /> or tho.c w•nnn. dinrtl~ n pm.ible for eatherin~ tha• infurmati~m. the information <br /> wbmiltrd i.. lu the bra of m~ Anowlavl~K~ and la•Iref. trix, aarurate. and cumpktr. <br /> I am aware that there arc.ignifirant <br />rnaltir. for aubminin <br />falcr information SIGNAT'`JRE OF PRINCIPAL EXECUTIVE _l - __ <br /> p <br />g <br />. OFF ER OR AUTHORIZED AGENT Arf EA <br /> <br />TYPED OR PRINTED includin thr mibiliq of one and im nammcnt for Lnowin i datinn.. <br />x w P Ka ~ NUMBER <br />CGOE , YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence a!I attachments here) <br />EPA Form 3320-1 (Rev. 3+99) Previous editions may be used <br />003 •' Thi. i~ a 4-dart firm. <br />