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PERMITTEE NAME/ADDRESS Ilncladr Facility .~'arne/locution if fhJJiren(1 NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />~_ !_ <br />ADDRESS ~ t ~.:. 4 <br />P,t]X •_. PERMIT NUMBER DISCHARGE NUMBER <br />~-fi MONITORING PERIOD <br />FACILITY j-jOf{ j ZGa'` _ t~l_ <br />LOCATION YEAR MO DAY YEAR MO DAY <br />i_q C G~ 8 i ~ FROM TO <br />i 4a`Irt` L: .: •'_ . Ni T taF Mat~tAt3FR <br />Form Approved. <br />OM8 No. 2040-0004 <br />5R ~M L NE DRNG Tt~ <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 ~ <br /> PERMIT - f=~ •,:.:, - <br /> REQUIREMENT ~ ~ ~ •- c <br /> SAMPLE i <br />~ • <br /> MEASUREMENT ~~ <br /> PERMIT ~Zi=t-'CiF+ . -~~pl~i;~- <br />- REQUIREMENT :30Dr. Dfi I L <br /> SAMPLE - _ _ <br />/ ~ `~ <br />~ <br />i <br /> MEASUREMENT <br /> PERMIT - ~.._: ~; :2EF(ar~.-f :-.f'df? ~ f.i,- :. ;~_ - <br /> REQUIREMEN7 3~i:71c1 AVC - ~: `. !•~' <br /> <br />SAMPLE ,: <br />i <br />y <br />~ } ~` uL MEASUREMENT - '' <br />., ~ --,.-. _. - PERMIT ...; ; 3- ..~+t - <br /> REQUIREMENT ~ ` '' - <br /> SAMPLE I <br />- <br /> ~ ' <br />~ <br /> MEASUREMENT - ~ - j <br /> PERMIT ~ ., , -• - .:-.~••tt• :. *2 L.; ~ ~_+H T !=i = t <br /> REQUIREMENT +•^:j'jp f:, :: 1.- ~ 'r ~ ; i <br /> SAMPLE <br /> T <br />A K- i ' <br /> ME <br />SUREMEN <br /> PERMIT .... . _ , t- ~ _, <br /> REQUIREMENT `':;:';"-, :;°+~C; ~lr! ~ i"~( 'hX , <br /> SAMPLE { <br />- ,{ -- <br /> <br />MEASUREMENT ; <br />~ <br />~ <br />`f , <br /> PERMIT - - ~ -..- . ~>± . ~ . L ~ -. . <br /> REQUIREMENT ' _' :- • s `:' ., - ` , r., , <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I (Y'rtlff UndCr penvhl o(IpN (hat Iblh dUIUnlClll atld aR allachmcnH Nert• <br />' TELEPHONE DATE <br /> ptrpured under my dircetion nr sapcn~ision in ucnlydanrr with a +) <br />+tem de,iµned _ <br />' <br />-- <br /> to ~ sure that qualified prrvmtlel pnlpcrly galJxr atld evaluate thr information _ <br />- - <br />~ <br /> submiUed. Rxsrd Im my inquiry of rile person or pervlns Nho manage the .~ stem. ; <br />" - Nr 16aSr perwm directh rrsponsiblr for Kathrring the information, the information { ~. ~ _ <br /> <br />e and brlief <br />accurate <br />and rnmplrlr. <br />ubmitt <br />to the IMd of ms kmlN (ed <br />true <br />d is <br />•- ~ ~/~ ~ <br />~ -• <br />~ <br />'/ <br /> , <br />, <br />g <br />. <br />, <br />s <br />e SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PRINTE75 I am aNan that tlx•re are+ignifieam penaltie+for wbmiuing fate inh•rmatina <br />irlduding the rssibility of 6ne and im rnunment Cur ktluNin iulatiuns. <br />p P - g ` OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />DE YEAR MO ' <br />' <br />DAY <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />30004; C~7r <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. <br />