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PERMITTEE NAMEIADDRESS llndudr F'otiGty.YltmriLm•ution rjlhjjrrrnt3 <br />NAME !-~-'- <br />ADDRESS - ~ ' <br />i~liSi f•li~iFJ STREET <br />» i LAD G G S Z OE-s <br />FACILITY ~;Ef~jC 1 f t7 t~ANYCW f'~11~L <br />LOCATION ~jT:'rlli C~ G I Ot3 <br />a T ,. .~r~R ; ntn'rr-I><., . F~ T P.tF -vIAIVA•.".:1=R <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 />Folrn Approved. <br />OMB No. 2040-0004 <br />L'I~CHAFtGE TU JcFF <br />NOTE: Read Instructions before completing this form. <br />PARAMETER OUANTiTY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX NALYSIS TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT - <br /> ,.-- ,: <br /> PERMIT <br />„' <br /> REQUIREMENT r"!' I <br />, <br /> SAMPLE <br /> MEASUREMENT <br /> - ,. <br /> PERMIT s .. ,.~ .. ~ t'' `.' •' ' ~ `~' f'i ~. : i <br />• REQUIREMENT <br /> SAMPLE ~,~ ~, ~' <br />- ~~ <br /> MEASUREMENT i <br />~ <br /> PERMIT ~ l~~ <br />f , <br />'', A V i; <br />L: r'; 1 L- ` ~ x. <br /> REQUIREMENT V <br /> SAMPLE `, ~ `~ <br /> MEASUREMENT ~ <br /> <br />- <br />. _ <br /> PERMIT } P.'Ji= ._ .:. i.j; <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .- - -• .. - .. N <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - ~ _ , ~ ., .. _.., _ , - <br /> REQUIREMENT •- '-3'' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certir~ °"der penau. of Iaw that thi. dorumeN ,md alt attachntrnh werr <br />prrpured untlrr m. d,rn~tinn ur •n{w~ru+iun m ,m ordnncr with u .yarm dreiRn~d ~ - <br />r ~ l / <br />~ ,.~ TELEPHONE DATE <br />_ _ <br />I, ~ l~i ~ <br />G ~ 'y ~:, ~r '"' <~ u (/ ~ ~ In a..ure that ynahrird perwmnrl pnNlerit Rather am! e. uluate the infurmah.,n <br />er.na. who managr the .stem <br />in of the <br />erwm nr <br />•d <br />n <br />i <br />b <br />i <br />d <br />N ~ <br />-// L ~~ ~r <br />. <br />~ <br />~ <br />! ' <br />~ . <br />p <br />" <br />m~ <br />m{u <br />p <br />.n <br />m <br />ttr <br />. <br />aw <br />or tho.c prnon. direath rtwp,nviMr for gathering the inrormntiun. the information ,, ~ . ~~ <br />(r /~~ , <br />`, <br />wII' ~I ~ /rj ~,.U / --~ /~% ~/ /~ <br />__ <br />' <br />l <br />t <br />d <br />m <br />let <br />• <br />L <br />/ ~ ~ ' ~ = - i ~ <br />' ) <br />Ut <br />I ~ ~ <br />j <br />~ ~ <br />/ <br />~~ <br />~ true, acrutro <br />e, an <br />co <br />p <br />e. <br />a <br />Ik <br />wbmittrd ia, to tht brN u! m~ k:mwledy?e amt <br />SIGNATURE OF PRINCIPAL EXECUTIVE , / ~ <br />r ~ <br />' <br />~ <br />~ ~~ 1 am awarr lbw them are .i>;nifnant peneltie~ for whmitting fal.e information. Z <br />N AREA <br />TYPED OR PRINTED including the txn+ibiliti u( fine em1 impri unmem fur Anowing.idations. OFFICER OR AUTHORI <br />ED AGE <br />T NUMBER <br />D YEAR MO DAY <br />COMMENTS AND E><YI_Arvtaltvrv Vt HrvT VIVLHIIVIYJ (rTC/C/C/1(:C OII alto,./Illlcllla .I ct <br />SI <br />.~;VI <br />cPA Form 3320-1 (Aev '-r<L~ ,:~. ~. <br />Thi` is a -l-Hart I<trm. PAGE of <br />