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PERMITTEE NAME/ADDRESS ilnrlude £arilih• .\'amdl.rxation ijlAJferenU <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />O E; I ~,,.,` <br />t~gI•YAG~i'. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />i~tU liIS~FiARGE ~ __,I ~~~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF <br />I SAMPLE <br /> <br />TYPE <br /> ANALYS <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 rrrtir> under pa•narn or law mat mi. d~M nmrnt and aU auachmrnb wrrr TELEPHONE <br />prepurrd under m+ dirMion or wlK•n i+iun in uccnrduncr with a ,T,Irm designed <br />to u„are that quulifid prrwnna4 proprrh gather and e, ahmte tM• information ' DATE <br />+obmitled. hour! ~m m) inquire nt Orr prrwnn or perwm who manugr the ,)+Irm. ~/ <br />or Ihanr penom dlrccrh rol>tm+ible for guthrring the informwtion, the infnrmuUon <br />+uhmittarl i+, In the In•+I of m7 Annwiedge un<I Irlkf. true, uaYUnta•. and cwmpkte• SIGNATURE OF PRINCIPAL EXECUTIVE <br />I ~ _ <br />I•- I v <br /> I um aware Ihal Iherr art +iYmfkem Ix naltirs for whnulting false infrmation. AREA <br />TYPED OR PRINTED including rhr fwn,ihilH~ of flnr and impri+onmenl for Avowing aioL•nion,. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />,:Ji <br />F? . <br />EPA Form 3320-1 (Rev 39°1 Prevn-.a :-~inoc= .., :: ; ~_ ~sr:J l~hf, i~ ,t -+-h<Ut Il~tni. <br />