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Form Approved <br />PERMITTEE NAME/ADDRESS pwerbferYyNr./L«.riew I/Dl~q NATION AI rl>ILUTANT DISCHMOE ELIMINATION SYSTEM rrNPOESI oM8 No 2040-0004 <br />DISCHARGE MONITORING REPORT (OMR) <br />NAME <br />ADDRESS NU. ,3 - - ,. <br />~~,,~ ~ 7' ~ PERMIT NUMBER dscHMOE Nl1M6EA '- F I PdAL. ) `'~ <br />IA .....E WI=T l"FSTIf~IG FOR aCilA <br />MONITORING PERIOD <br />FACILITY NO ~~ r ~ . YEAR MO DAY YEAR MO DAY <br />LOCATION ~28E~(• FROM TO <br />_^, r,._ ; ,, NOTE: Reed IMtructiof» b~iwe comp{etinp th{e ftxm. <br /> <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />of <br />, <br />~Y~s SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS µ, <br />, <br /> SAMPLE <br /> MEASUREMENT <br />.lis ~'i i 1 ~ ~ F=.:'. <br />(;; - PERMIT <br />REQUIREMENT :.~~ ~: #~##~ fi ;r ~' k'fi' <br /> <br /> SAMPLE <br /> MEASUREMENT ~ ` ~ <br /> ~ i:, <br /> PERMIT - ,r r. ~ ~ . } ~ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT _- <br />NAME/'fiTLEPRINCIPAL EXECUTIVE OFFICER l"11;1]° `pe°.IJo I.wln.tlhhdocumrnt.nd.tt.tlsch~ce..ere TELEPHONE <br />rRw~ ruder mr etreruon sr wper.hlon In sccord.nee »Im . f7stem et.tintd DATE <br />to mnre In.l a..nnta penonna rrorenr ~.lher .nd e.slu.le the Inrernullon <br />snbmltted. bred en ~r Inquiry of tht prrsal a person .ho msns~e lht ~rslem. .. <br />or those perrne direttl~ ra~pondbk fa ~slheArK the Informsllow, the Informsl{en - <br />.: ; l ~ :: ~ ~ ~ ' .' <br />-. <br />mbmitled b. W the Heel of ~n~ tntrwkd~e snd bdlef. Irot, sccunle. snd cempkte. <br />EC:t/TT/E ~ ) <br /> 1 sm s~sn Ihsl lher: sre slpJfksM pensltlrs -or wlbrrrltln{ fsbe tnfonnstfon. HONATVRE Of -RINCIrAI EX A A <br />NUMBER <br />YEAR <br />MO <br />AY <br /> of fine snd Irnprlsonmenl for Lnowtn~ rtelet{one. <br />dbilll <br />I <br />ndl <br />IM OFFN:fR OR AUTHORIZED AOEMT CODE O <br />TMpED OR PRINTED r <br />ne <br />n~ <br />po <br />COMMENTS AND EXPLANATION yr nni vlv~nllvna trt~nermc~ ~...~~.~.........~ ..~.~. <br />r_, ~ <br />~- <br />I t nta i <br />EpA Form 3320.1 ~Re'v 3199) previous ed~bons may be used <br />