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PERMITTEE NAME/ADDRESS (6rebJeF~eWryNaararLoe~rlon (/D(Qlrrenr)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESI
<br />DISCHARGE MONITORING REPORT /OMRI
<br />PERMIT NUMBER wscNARGE NuMeER
<br />MONITORING PERIOD
<br />YEAS M0. DAY YEAR MO_. DAY.
<br />FROM ~+. .c c. ., TC a r. ._ a.
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: R~~d Ir»tructitxtt b~itx~ compl~tinp this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREGVENCY
<br />of SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER r «rtny u v pens ty o law that m
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<br />submitted h, W the bnt of my knowkd(e and beeer. true. attvnte,.and mmpkla
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<br />IONATLRE OF PRINCIPAL EXECUTIVE J )
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<br />C f { I am awaR that th[R are sl(n111Unt pendHes for aubmittln( hbe Infornutlon,
<br />TYPED OR PRINTED
<br />Indudln( Iht possibility of ene and Imprisonment for knowln( ridatiou
<br />/ OFFICER OR AUTHORIZED AGENT
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS ANO EXPLANATION OF ANY VIOLATIONS (RN~r~nctr oI/ ~ttacnmtrnta nt'r~l
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<br /> r•2~i~li~TS,
<br />Previous editions ma be used. t~ 1~-, 'r f! t~~•~Tt~1$,~AJ4.rp~i'~~rm. Y PAGE ~oF
<br />EPA Form 3320-1 (Rev. 3199) Y
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