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P£RMITTEE NAME/ADDRESSQweii~rFrWryN~r~L«rrawl/D~..a.r) <br />NAME <br />ADDRESS - <br />- a .. .. .~ .. ~ JV v.. i.J <br />• ~ Gli1l 111 jJ <br />LADY. G• <br />FACILITY ~ ~ D E h (~ k i :i G ~ {~ V 'i t! ~1 1 <br />~ocr-TioN P A L 15 A D r• C~ <br />I. U V( 1~ . L t J <br />Form Approved. <br />NATION AI POLLUTANT DISCHARGE ELIMINATION SYSTEM (INPDESI OM8 No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMEER _ ~ ~ _ <br />bl ~ - MONITORING PERIOD ~ ' <br />_ YEAR MO DAY YEAR MO DAY , _ <br />FROM _ TO ~ ~ I <br />NOTE: R••d If»ttuctlofi• b•twi empl•tlnQ thl• twm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, U~NCY <br />FREO SAMPLE <br /> D <br /> EX '~"~~~5 TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br />r SAMPLE <br />' <br /> MEASUREMENT <br /> <br /> PERMIT .. <br />_ <br />I <br /> REQUIREMENT <br />.. <br /> al ~,~ <br /> <br />._ SAMPLE <br />, <br /> MEASUREMENT <br /> PERMIT ~ - <br /> REQUIREMENT ; _ I, <br /> <br />~~ r ~ ~ SAMPLE _ <br /> MEASUREMENT <br />`,. , <br /> PERMIT <br />_ , + <br />- ., <br />n ! / <br />r r. ' <br /> REQUIREMENT ; <br /> , "C T~. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br />REQUIREMENT - <br />..r.,. _ <br />.. 1, <br />c <br /> c ; <br />_~ _ <br />~ SAMPLE I r <br />t <br />. - t .. MEASUREMENT <br /> PERMIT .. r'_ I:~ORT .~ - <br /> REQUIREMENT !i <br />~ , ~ ~ r. <br /> SAMPLE <br /> <br />. MEASUREMENT <br /> PERMIT (/' : ; : r', l T V i ;: L A <br /> REQUIREMENT <br />' <br />NAMElT1TLE PRINCIPAL EXECUTIVE OFFlCER ' """' " " p`""~ ° I•. IAet th h document <br />end .II .llecnenrnet +ere TELEPHONE DATE <br /> prepared under my direttlon or wpr r+Elon In etrordenn .rlln a tftlem dtsltned <br /> <br />-~- to more inee queMfled personnel P~H7 LetMr end r.elvelt lne Inferrrtellon <br />snbmleted. bred on m~ Inq"Iry of llet person or ptrsortt wno menete lnt tys/rm, <br /> eK (note penore dlrertlT rnpord bk for telheAnt the Informellon, the Infnrneellon <br /> wDmllted h, la !ht bnt of m~ kewwledte end AeMef, lrvr, e[eslrfle, end compkle. - - <br /> I em e..re uel Inrre ere sltnincenl penemrs for abmimnt f^he Intormetlon, iIONATVRE OF -RINCNAL EXECUTIVE - ' <br />TYPED OR PRINTED I"Audint IM podemy ornne.nd ImpAsonmenl ror-no.int .Ideuoa>_ OfFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS ANU t/CrLnren a evr. yr rs.e . . e..~... evn~ In ~r ~r mc• ern ouere.nnron to< reerrq <br />.. cites, s~b~rcT :~, ecFC~r. cf rECCF <br />EPA Form 3320-1 IRev 3:99! Previous ed+?ions may be used TII1S IS 3 d-pall IO(ITI <br />