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PERMITTEE NAMElADDRESS ~lnrludr Fariliry :Ya/nr/f.Karinrr i/DiJfertnri <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />L_~~tr c taat~~ . ~'~ ~ ~:ir PiAP~i <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />~HRC"d:.% WET -E° <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />J <br />~ <br />~ <br /> MEASUREMENT ~ ~% ' - -- <br />- PERMIT tf ~rir;~ ~ ~ _ :-: -, - _ .~-.~ -Y ~• ~ - <br />i REQUIREMENT I';; ~ ~ t is ~. i Y <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 /> AEQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certih undo prnatn r.r mw that thi+ducument and all mtarhmenLs were <br />r <br />r <br />ul <br />dir <br />ti <br />nr <br />i <br />with <br />y <br />d <br />d <br />d <br />i <br />i <br />d <br />t <br />i <br />- -• TELEPHONE DATE <br /> p <br />rpa <br />m <br />rr my <br />nn <br />+uprn <br />rm <br />n uanr <br />unrr <br />r <br />rm <br />rs <br />gne <br />r <br />ev <br />+ <br />a + _ _ _ - <br />- <br />~ <br /> lo a++urr Ihal yuali(IeA prrwnnel properly Kathrr and r+:duatc tln Information ~ <br />_ _ ^ +uhmiued. Raxd on my inyuin n( the prrmn ur peootn oho manage thr sTctem, % ~ <br />-"- nr those lunom dtre+•th mp,mitdc fur teathrring the information, thr informstMn =' <br />~' - <br />- subntittrd Is, to the lust o{ my gnowfrdge oral lulh•(. true. uacurale, urtd trartpltte. J <br />~ ' ~ "" ~ ~ 1 <br />th <br />t (h <br />ifl <br />lti <br />iLLi <br />i <br />d <br />f <br />b <br />f <br />l <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> am aware <br />a <br />ere arr s <br />gn <br />rw <br />prna <br />rs <br />or •u <br />m <br />nR <br />a <br />n <br />orma <br />om. <br />+r OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED inclwlinp the pn++ibilih of finr and imprFrmmem for kn~wing+iu(atinns. NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!1 attachments here) <br />'::1= D1 <br />- . - -- - ._ _ - .. R E <br />EPA form 3320-t (Rev. 3%99) Previous editions may be used. -This is a 4-patT tOrm. PAGE OF <br />