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PERMITTEE NAME/ADDRESS Untfudr FariGly:Ynme/Laratinn if Ui~/irent~ <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />DISCHARGE MO ( ) <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 />t'_.'L~: i~ir <br />F - 1-TNAL_ DEl <br />trcl,, ,•t_, t.!nlr.l~r•. ~~RiR 7[?yl.!t?f3Af?n (:c~t <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, 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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ ~. , ; _ , <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PEAMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtih under penalh nt lave tltal Ihi. d~NxIt11'xl and all uttxhmcnL+ wrrc <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> ancr w <br />prcparrd under m~ dim•tion nr wlxr+ <br />+i~m in acror <br />x +y+trm <br />r+iKne <br />t <br /> to a+wrr Ihxl ytmlificd prrvmnrl pnyw•rP Rxlhrr and r+uluatc the information <br /> +uhmHtad. Raved ..n my inquiry of thr prrw.n w perwn+ who tnana>te Ihr +r+trm. <br /> or Ihox prr+.m+dirrclk re+p m+iblr for guthrritq; Ihr information. the information '~ <br /> whmhtad i+, to the be+t of m+ knowied4< mtd belief. Iruc, xccuntr, and comp6rtr. <br />h <br />b <br />i <br />f <br />l <br />f <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED ornat <br />I am aware that there are +iknitknm pena <br />ir+ fur +u <br />ning <br />a <br />y in <br />on. <br />m <br />itnludinK Ilk gbllih' of rinr am) Im rnonnxnt for know inl; Jolati~m+. <br />I~ P ' OFFICER OR AUTHORIZED AGENT AREDA NUMBER YEAR MO DAY <br />COMMtN I S ANU txr-varvr~ t wtv yr iaty t vtvl_ia t Ivt~a (r7C/CrC114C OII auat.ruttcrna ncrc~ <br />EPA Fvrrn 3320-1 iRev _ =~"i. :. -.._ .-...~'r~~< r-~a. _,._ _.. ~J <br />T1'lts IS 3 4-part form. PAGE OF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NITORING REPORT DMR <br />