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PERMITTEE NAME/ADDRESS i!n<tudr furifftt:Vamr//.oration ifpifferenq <br />NAME ,• ` _. <br />ADDRESS _ _ . .' i I } •; ~_ <br />~~~ b=,=~ <br />f- <br />i <br />FACILITY y(~"f x~(ti; 1•f ~. I ii' <br />LOCATION •_p t,:.3 ~s <br />LAIVC~ L~ r,. ;_ ''t i , 1`1ANAvER <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 />f P.IE I'iRPi~ 3R I B TD 71..'T I L,~ _ <br />. -<_ _ <br />NOTE: Read Instructions before completing this form. <br />PIT°E~ { <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />- PERMIT ., a ~;t „;.: ~ i~ .~-~ ~ .. : ,. <br />- ~ REQUIREMENT =: ~ ~ f•1H f • - <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 crrlif> undrr penulN of law that this dorunxnl and all mtuchn/ents wrre <br />d <br />d <br />di <br />ti <br />~ TELEPHONE DATE <br /> prrtrarr <br />ull <br />rr mr <br />rec <br />on or .uprni.iwn in :wrordoncr xilh a s~ <br />strm drsiRned <br />_ <br /> to uswlrs• Ihal ynalifird personnel prnpertt Rulhrr ulld tsalumr the informniiun ~- '---~- <br />--~-" .uhmitt d. 8axd an mt inyuin u! thr perum nr perwm xho munaKr the sr~trm. =it <br /> <br />i or lhnsr person directly n. pnnsihlr !ar kntherink thr infarmatilm. the Information ` _ <br />i suhmHtcd is. u. Ihr best or m}~ knuwled{Ir and belief, Irue, ass~uratr. and compktn ~ ~ <br />~ ~ <br />i I <br />; <br />• ~ ~ <br />1 um swore thm them are a>Zniricant ps•nahie. for submittln>; false information SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />` ' L ' <br />~ <br />TYPED OR PRINTED . <br />including the pussibilih of fine and imprtwnmrnt for knuxinK rildatione. OFFICER OR AUTHORIZED AGENT CR~E NUMBER YEAR MQ DAY <br />VI,JIYI It/lGl\IJ MI\V CAr'LMI\M rIVI\ Vr MI\1 YIVLMIIVI\J (lICICI CII{4C i1ll i7llrJlilllllClllD !IGl Cf <br />( TM7'T <br />EPA Form 3320-t (Rev. 3199) Previous editions may be used. <br />- `• Tfi1S 1`i i3 ~=(1:iTI FOitTI. PAGE OF <br />