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PERMITTEE NAME/ADDRESS llnrludr Farilih VamdLiratiwt if lhffirrnU <br />NAME <br />~ ADDRESS <br />FACILITY <br />LOCATION <br />DISCHARGE MONITORING REPO (D ) <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-ppp4 <br />MIP~>n PftAIP <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 />NAMErfITLE PRINCIPAL EXECUTIVE OFFICER I renif~ under prnalN of law Ihut thi. darument and all attachmenh wire <br />• <br />h <br />• <br />d <br />i <br />d <br />~ TELEPHONE DATE <br /> n spsd <br />prxpnrcd under m. dirrdiun ur wpen <br />isinn in accordata <br />c wit <br />m <br />e. <br />Rne <br /> to nwn that yualificd penonnrl proprrh gmbrr tatd e~aluatr the information <br /> 5ubmittad. RascA un mr inyuin of the perwm ur perwms who matuyle the .rarm. • <br /> or thue prnons direcU) re..pon.ibk rnr gntherin)Z the information, the information ' ' <br /> aahmiurA ie to tha• hra of m} AouwicdGc and bcticf. true, an~uratr, and c~anplete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there arc ~ignificam prnallir. rue whmittin¢ fnha• infarrnutiixt. AREA <br />TYPED OR PRINTED including the pK.ibitit~ orftnc and impriuatmrm far -nowin~ ~iolatiom. OFFICER OR AUTHORIZED AGENT ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />I EPA Form 3320.1 (Rev. 3199) Previous editions may be <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />RT MR <br />IU00~ Th <br />