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PERMITTEE NAME/ADDRESS pnrML i~rfbry Nw./Lerufon (/Dl,~r.rwr) <br />NAME <br />ADDRESS _ .., .. .... ... ~ _, ... .. _ .. _ <br />. :..ox i=~.~cJ <br />::.ADc CQ bi`.16 <br />FACILITY SIDE ~ cikTii ~ SCU1H ,Ittc.S <br />LOG'S i'i.il~AUc: CtJ :i1~1b <br />ifiN 1_ K~C;IiFh V_U_ <br />Form Approved. <br />NATIONAL VOIIUTANT OISCHMOE ELIMINATION SYSTEM /INPDESI OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR/ <br />,t,n :.~) <br />PERMIT NUMBER DISCHARGE NUMeEq _ C ~ re , L~ ~:: <br />MONITORING PERIOD ~ `" - " <br />YEAR MO DAY YEAR MO DAY <br />FROM TO r . r~ <br />NOTE: Raad Irnttuctlorw b~fora,Eompl~ti~p thin form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREOVENCY <br />SAMPLE <br /> <br />EX OF <br /> ANALrs+s TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . ' ~ ~, ~ 1 ~ S .: ii <br /> REQUIREMENT _ <br /> <br /> <br />r SAMPLE <br />• <br /> MEASUREMENT <br />`. 1 ~ ~ PERMIT ._ f :, . _ . ~ ._ , , <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT , , :-i :. r G i~ ~ y J _ <br />, .. <br />y REQUIREMENT 1 ~, _ ~ r ~ C ~ Z <br />• <br />r .. SAMPLE <br />, <br /> <br />_ MEASUREMENT <br /> PERMIT _,..il .'i i,~rlt1;'1 ,v. ... t'.LY Dix- <br /> REQUIREMENT I ~, ~, A h v V ~" r Y I. <br />..., <br /> SAMPLE I <br />~ <br /> MEASUREMENT <br /> PERMIT ..i _; Y ,:;r,~ PtF.L`f ._~;';~ <br /> REQUIREMENT <br />1. 1 t.:{ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />~_ <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />1 ftrt11) a er prn• IJ a b. ~.1 Ihh dorvmrnl .nd 111 .IlKhmtnb wtrr <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFICER <br />TELEPHONE <br />DATE <br />eRw,~ under ml dir.rllon or r+yer.Non In .ecord.nce vllh . s>>Irm daftned <br />Io emure Ih.l au.llnre perwnnel yrOyerl7 ~.I her •nd t..N.lt Iht Infnrnulbn <br />- <br />I <br />l <br />submllled. stare on m~ <br />nQu <br />r~ o! the person or penoro who m.n.~r IM erelem, <br />or tht.e persore dlrec/l~ mpo.elbk for (.IAMB Ue InfrnruUon <br />the Infonrrl{rm ~ ~ <br />, <br />fubmllled hL to Ihr bell or mr -ne+W <br />e •nd btMef <br />Ir <br />l <br />d <br />kl _,. <br />~ <br />, <br />Ye, .ecurs <br />e. •n <br />comp <br />e. <br />1 .m •..n lw.l Ihrn en sl~nlrlc.nl pendtla for wbmlltln~ f.be Inforrrotlon <br />tIONATURE OF /AINCIrAI EXECUTIVE _ _ <br />nPED OR PRINTED , <br />Includln~,hrp.xvh~ui.ornne.ndlmPrhonmeniror-no.In~.IW^unns OFFICER OR AUTHORIZED AGENT CODE NUMEIER YEAR MO OAY <br />COMMENTS AND EXPV{rvw { wn yr nn r vrv~n I Ivrra rnn~rmc• eln ~rwcnmmrs n~r~i <br />EPA Form 3320-1 (Rev. 3.'991 Previous editions maybe used , This IS a ~-pan form. PAGE OF <br />,~ <br />