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PERMITTEE NAMElADDRESS Nnrlrrde Facitiri.\amr/Loration ijlhfjerrruf <br />NAME , .. L-!_ ~~ <br />ADDRESS - - '` r_ <br />uiP~•f f`IAIP~ ST~`cEET <br />1 gran ~a alos~ <br />FACILITY irlt_ f 30 Ci~,f~lY~!V C1IftE <br />LOCATION ~,_~{•„ ~ (} ~i i Oq j <br />-~. ADB I I~iOT©i~, i'r i tVE AIAWAC-FR <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 />Fom~ Approveo. <br />OMB No. 2040-0004 <br />'. <br />NOTE: Read Instructions before completing this form. <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 - .. ~ ~ _ <br /> REQUIREMENT ~, i:•< .•T:'`rY I.`i :"': <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - . - -- <br /> REQUIREMENT ';~~~~ .~:,th: <br /> SAMPLE <br /> MEASUREMENT ~ <br /> PERMIT - <br />, _ <br />• <br /> REQUIREMENT ~ ~~ ,. , "' ; r ` ; <br /> SAMPLE <br />~ <br />~. <br /> MEASUREMENT iI <br />!' <br />' <br /> PERMIT .,. •.r..t. r ... ., .._. <br /> REQUIREMENT ..- ':rsa i L ~ (": ~ !`i .! : i r? <br /> SAMPLE ~'• <br />•• - MEASUREMENT <br />~ PERMIT ... , _ _ - . - . - <br /> REOUIREMENT r - <br /> SAMPLE ~ • <br /> MEASUREMENT <br /> PERMIT ~ .. .. <br /> REQUIREMENT i!`!"-~ ` G1_!~l~f <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~r r r .. ..., . .: ., . ,. .. - . _ <br /> REQUIREMENT 'C`?_•;, ^.. '_.-'~ : ~. :' <br />NAMEjfITLE PRINCIPAL EXECUTIVE O FICER I ar~'fl umirr penally of lax that thi+dr»unlrnl and all elWchmrn[+xrrc <br />d <br />ectio <br />o <br />i.iort in <br />urrd <br />r m+ di <br />• <br />cc <br />rdanc <br />»ilh a+ <br />d <br />i <br />ed <br />t A <br />i ~! <br />/ TELEPHONE DATE <br /> <br />/ _ J .I~ I' p/~ r/ / <br />i . 1 J `/' <br />r ~ ~ _ _. pltp <br />ud <br />e <br />r <br />n <br />r wpa <br />n <br />a <br />o <br />e <br />y+ <br />em <br />r+ <br />rtn <br />la a Burr IIuU yuuhrird prrvmm•I prnp•rlq Aathrr and r+uluulr for inrwmrriun . <br />/ ~/ <br />% ~ <br />' <br />[` 9 / , <br />( <br />• _, <br />~/ ~, ' / ` I - V <br />~ +ubmurrd. Rx+rd un m+ inyuin ur the prrvm nr prrti.:n+ xba mon»Rr ihr +~ vrrm. /r <br />f <br />/ <br />J <br />r <br />\ r r ..r those prr+nrt+directly re+portciMr for Gnthrnn~ the information, lhr inforntalMn ( 7 /.' ry <br />L <br />~ <br />. <br />' <br />~% <br />) <br />~ <br />~~ ~ <br />- <br />~ +ubmitkd i+. lu the best of mr knoxlydgr :md Ira•lirf. tr ur. xcuralr. end crmlple4. {~ <br />/t <br />/ r Y, <br />j <br />/~ <br />/ ~ <br />r ~ <br />/ j <br />/ <br />t-~'! <br />'-~ tam a»+Irr that there nrr vi{;ni(faam q•nunii for+uhmiumF fnlx informalkrn SIGNATURE OF PRINCIPAL E ECUTIVE _ Y.J <br />TYPED OR PRINTED . <br />inchadilyt the po++ihiliq of fine ane impri+omnrnt for knoxin{t +Mlmion+, OFFICER OR AUTHORIZED AGENT AREDE NUMBER YEAR MD DAY <br />l+V rvl rvIC 1\IJ NI`IV Cnr v~+r~r•+rrvr. yr rare r •rva_r+rrvr.+~ Ir ere. eara.e ora aaaoa,a rrrreraa~ rrer e/ <br />;- <br />:~ <br />;; i <br />)LIDS ~ i.i1IT APPLIED FOR ~=1C~Yf2, 24NR PRECIP <br />rq. 7aur~ ant-rTr_ ~t/lwnrT CIIR IG;'T rn rall~n~nl rat <br />•" J <br />I PAGE DF <br />EPA Form 3320-1 (Rev. 3!991 Previous editions may be used. <br />This is a -3-part tilrm. <br />