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PERMI'TTEE NAME/ADDRESS flnrfude F'atilirJ Name/hcation if lhQoenf) <br />NAME ' <br />ADDRESS - <br />FACILITY , .. _ i'i :.. <br />LOCATION ,`, ~ ~ ~ <br />hIVCE ~i+~DF, ;`:Ii~i)= i"1AiVAi3ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPOES) <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#fW=:~ ~ Le <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 />/ <br />- MEASUREMENT J. (,~ ! ' ') ~~,~ 1 ~ ~ <br />` / 'T <br /> PERMIT .. ~ ~ - •r vx , .r-: <br /> REQUIREMENT _'~'~'r, ,", .. T~AIL~Y Mi( I'".;C <br /> SAMPLE ~ •" <br /> MEASUREMENT -~~'~ " ~ <br />- PERMIT -~: -t ;f~•~•# R..P _),.- ~~;:,.. . ,. . ,. - .. ,. -.. -_ _, .. , <br /> REQUIREMENT I1~;5_t "'1t~',X ~.:r'=-. .. .. <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 />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I .•er4n under prnulq urlaw rnm thi. e~ vmrm and all altaebmrntw ~rre <br />d <br />d <br />~ <br />~ TELEPHONE DATE <br /> prepared under m. dinrtiun ar suprnision in x <br />rordam <br />e with a .atom <br />rtiyrne _ - - ~ _ <br /> W usxtrr Ihut ytwlifird perwncel pr„prrh Rathrr mtd rcaltwlr thr information ~ <br /> wlrmitted. Ku rd ,x, m~ Inyuin ,d the prr~on nr penum wbn manage the c~stem, - l <br />" wr thaw penons directh respm.ibk rnr gathering Ibc infurmatlon. Ihr intonttatluo - -- J - <br /> +uhminedi. <br />lothelawt,dm <br />knowlydgcandbelirf <br />Irue <br />accurate <br />andaanplete ~ <br />,tai <br />- ~ <br />~ . <br />. <br />. <br />, <br />. <br />} <br />i $IGNATUREOFPRINCIPALEXECUTIVE <br />~ I tun aware That there are significant penalties for eubmitl <br />ng rake informmian, <br />D AGENT <br />FFI <br />R <br />R A <br />TH <br />RI AREA <br />TYPED OR PRINTED imiuding the pKSibilitr of 6ne and imprkonmenl for knowing ~i,dations, O <br />CE <br />O <br />U <br />O <br />ZE CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />,c <br />' J <br />EPA Form 3320-t (Rev. 3199) Previous editions may tie used. <br />LIL:'. ~11C 11 i1 -~- <br />