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PERMITTEE NAME/ADDRESS ~Inaludr Foy drn dame/!oration if Diffirenn <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 />~ ti- i i~ C:~*! <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX Y <br />I TYPE <br /> ANAL <br />S <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT <br />I ' <br />~ ~- <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />t <br /> MEASUREMENT <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 />-• TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrrlif) under lw~nalts of law that thi d,aununt aral all ultrahmrnh wrrc DATE <br />/ <br />prrpared undrr m. dirrainn or wrprni+inn in ara,rdana'r with u y+tem de+igm~d <br />bi u~+urr flat yualiriad Ia•rwmna•I pn,pcrl> 4ather and r+ulaata• Iha• information ~ <br />+ubmittad. Ruard on nn inyuin o! thr pervm nr penon+ whu muna>;e Ihr +c+tem. <br />i <br />h <br />i <br />f <br />i <br />on <br />nn. t <br />n <br />ormat <br />..r tho+a• penun+ direa•th re.p,m+iMe fnr {;uthrrinK the infnrmnt <br />e <br />~ <br />urutr. and rnmplrte. <br />+uhmittad i+. to the Ia~H of m~ km~wledRe and belief. tnx. ~. a <br />SIGNATURE OF PRINCIPAL EXECUTIVE - <br />~' <br /> I am awurr Ihut there are significant panultiea far wbmittin~ filar information. AREA <br /> ri+onmrm fnr AnnwlnK +i,dation+. <br />aa+ihilin of finr and im <br />in <br />huli <br />the Of7FICER OR AUTHORIZED AGENT ODE NUMBER YEAR MQ DAY <br />TYPED OR PRINTED p <br />c <br />ng <br />p <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev , - Fr,:~,.„_ ~..!•z .., .-.. ,._.cl This I: a -1 Karl Ii~rnl <br />