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PERMITTEE NAME/ADDRESS ilnrludc FeriGry :Name/L~ratinn iJlh%Jrrrnr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />:'i' 8142+ <br />CRFc <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 />:H;'t;fUM1ii"iD T~? I D /HUI3I <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ- FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crnif~ under penalh of la» that thi+d~wumrnt aml nll ultachmrnt+Nert <br />ith <br />d <br />i <br />d TELEPHONE DATE <br /> prepared under m~ direrliam ur wprn i..+ion in uccordanac » <br />a +~atcm <br />n <br />Rix <br /> to a+wrr that yualifird penarnnrl pruprrl~ gather and e+ahwte the information <br /> suhmittrd. Rax•d nn m. inquiry ,d the per+aea ar prnun+ » hu manakc for +y+trm, <br /> ur thu+e pennn+dirreth reapun+ihk for 4uthrring the information. the information <br /> whmitted i+, w the Le+t n! m+ kna,»hdge end tx•Ikl, true, wrurala and rumpleta <br />i <br />b <br />l <br />i <br />l <br />l <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED orma <br />on, <br />I am a»arr that them xrc +ignJcam pcnult <br />n fur w <br />m <br />u <br />ng <br />a <br />+r <br />n <br />including lha• pan+ihilih u! fine and impriwumem fur knowing +iulatioro, <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />YF CLAIM APPI <br />A•--5 FOR DURDEN <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. '~IO4~I•`r "Chic is a =f-part form. <br />