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1'ERINITTEE NAME/AGGRESS pwdrr F•rWnN~+.rL«•nen UO(DFr+~r/ NATION AI GOIIUTANT DISCHARGE EtIMINATIOM Sr3TEM (/NPDf.SJ <br />NAME DISCHARGE MONITORING REPORT (OMRI <br />ADDRESS _ <br />~' ~' • -- `~ `' PERMIT NUMBER DISCHMOE NUMflEN <br />i 5+4D~ <br />I Dr '~Lfi ; MONITORING PERIOD <br />FACILITY /~ " ' ' <br />LocATION = P iY1L I SADE FROM Y AR MO D Y TO Y AR MO DAY <br />Form Approved. <br />OMB No 2040-0004 <br />s`i f <br />NOTE: R~•d k»truedons b•Tw• compi~tinp thi• Tam. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX F^EauENCr <br />OF SAMPLE <br /> <br />TYPE <br /> ANAirsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />' SAMPLE !j <br />~ .'I / i ~ ( <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENY - . <br />.•.:.. <br /> SAMPLE ,~ ,a ~;. <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />'I`~~~~~( i•i;~;, <br /> SAMPLE ~ <br />~ "? 3 <br />• <br /> MEASUREMENT <br /> <br /> <br /> PERMIT - <br /> REQUIREMENT ' <br /> <br /> SAMPLE - <br />r • <br /> MEASUREMENT ~: <br /> <br /> PERMIT :-~ t ~:.• <br />r ~ <br />- ,•, <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 OFFlCER 1 ftl'lli~ Y r Dr•• q o .. lb•l UN donrm.nl •nd JI •u•thnenu were ~ "~ <br />I TELEPHONE <br />DATE <br />prepared under my direction or •upereMon In dreord•nre rllA ..~rlem ee•ftned <br />le sure Ih•1 qu•Mfled perwnnei proptrt~ t•iber and rr•iu•Ir IM Infnrrn•Ibn 1" <br />( <br />•: f, rte. ;_'_ <br />_. ~' <br />~ <br />wrbmllred. Seed nn m~ Inquiry of Ibe prr•on ew permnf rbo nun•tr Ibt •)slrm, <br />~ <br />~~ <br />~ <br />~ <br />~ ~ -- <br />w tba•e ptnov dlrMl~ re.poMbk for pthMnt Inr Infonn•Uow. Ue Inforrrrllnn ~ <br />' <br />~ <br />~ <br />` ~ ~~• ~, ~ . ; r - n 1' <br />` <br />' - ' ~ 1 <br />~ <br />'~ - ~- ~ wbrrllUed b, Io the be~l nr rm know 4dtt ^nd beNer, true, •(crnlr, and compkle. - - <br />~ <br />r <br />b <br />l <br />ln <br />r <br />i <br />re <br />•tl <br />iIONATURE OF rRINCI-Al EXECUTIVE <br />' t <br />LN <br />d <br />l <br /> • <br />rn are r <br />tn <br />prn <br />n <br />o <br />n <br />ew, <br />w •r.re I <br />I <br />nn <br />tla ror rubmlulnt f•-•r <br />TYpEp OR PRINTED InclrWlnt Ibr por/blulr or nn< •:d Imprtx,nmrnl for -no.lnt .Id•Uerd OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO OAY <br />COMMENTS AND EXPLANATION OF AnY vlv~A norys IHIM•r•gc• MI •fI•cnm•nts n.r•I 70TAL ~USP)rNDEU 80L I <br />? :J 1 1 ~) i C'~#1ts'i3 ~ s-part forth. - PAGE <br />EPA Form 3320.1 (Rev. 3!891 Previous editions may tx used <br />