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PERMITTEE NAME/ADDRESS (-aeirJriarWryNwa~Loe~rrow IJn(QG„mq
<br />NAME 4 i~A~'~'i=~ I'~i~iV~NG, ~I~IC'.
<br />ADDRESS Tf~~PI'~i~ ~'~ ~
<br />t'. Q. Q}: ~~7
<br />C'i~:~~IG. qd 1~3~6r'~s
<br />FACILITY Ti~t~iF'i~~i~ l~I6~i~'
<br />LOCATIONCR~3~~ ~Ci ~~,~~~
<br />ATTi~: t:3filY('~I~~ii`) {~. DU ~qZS, ~i~~8/U`i~i
<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM //NPDESI oM6 No. 2040-0004
<br />DISCHARGE MONITORING REPORT /DA4R) f~ ~ jij[)~
<br />PERMIT NUMBER DISCHARGE NUMBER ~ - i= T ~w~aL. i`1~~AT
<br />I'Qitt~? ~f~ T~ t"#IO~~i...i:' P°~i*~T'T OUL.~i-§
<br />MONITORING PERIOD
<br />Y R D Y D.Y
<br />FROM •- TO r«. ~. ~•~~ #~"4~ 1}~~e+,-~a~~Cy~ ~E ~#ii•
<br />NOTE: R~~d Imtructitxa b~tor~ compbtiny this Corm.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY
<br />OF SAMPLE .
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM. UNITS EX ANALYSIS TYPE
<br /> SAMPLE ~' 'tr i &;,
<br /> MEASUREMENT
<br />
<br />0000 ~. O O PERMIT •>:~ ~"~ ~' ._ .. ._
<br />~Fi=l~U~itfT OI;,CI~~ V~~.UZ ~~QU{REMEN7
<br />, _ •~•>4•~•r: i"1I1'+tIP~fU1"i
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<br /> SAMPLE . =:- 7-. ,: •r; ;;., . _:., - ~. ~
<br />^~`
<br />SU~i~ Ef~3~]~13 MEASUREMENT / '`
<br />
<br />005;30 ]. O O
<br />~F'i=i,.UE6~IT O~®~S VAL-!' ?<.s:;;PERMl7
<br />1tEt1[JIREMEN7
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<br /> MEASUREMENT
<br />
<br />OO~Sd~ 5 ~. O O
<br />~~r ~U~t'~T C~f~~~S ~~+LU ~ PERMIT
<br />RE{lUigEMENT
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<br />t i , :y SAMPLE ~- •;; - •.~ •xi •~ ~ ~• ~~: ~~- •t; t •~ ~r
<br />L tq~ ~_ ~ ~ MEASUREMENT
<br /> •
<br />Cl ~, Q f1r1~, ~ O O
<br />~~~~UL.I~IT O~t~SS V«~li-.U PERMIT
<br />REOUIREMEN7 ~: .. •li••~•I~•
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<br />i. ~ f~ V ksS SAMPLE '~ ~ :`:3c ~ it ..; 3t a'••n 3#•-!`r'k'#~r•i+: •k'r'h••:; •1#•ti?•Ye
<br /> MEASUREM NT
<br />
<br />035E3~ 1 O 0
<br />~~F'LUiwi~3' U'iai~~:, tlc~~U PERMI
<br />.kiEOUIR ENT
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<br />TI-i~U TRE~,Ti'1~ii#T' PE_~IR! MEASUREM NT
<br />
<br />500~s0 ~ O O :PERMIT '~ - F•kF•if•3"r .:_ I
<br />~FY= L.U~f~T Gf2~)~a~ tlt4LU ~t~auiaEMEN7
<br />.. 34DA Ai~'G DA I Y M ~10T~ ~~~, ~-~:
<br />• SAMPLE ' M"~',r.x. ,; c~--~; +, .: •,e -x~c• :_ r_ •~:
<br />O ~ ~u®Ltil~~3 MEASUREMENT
<br />
<br />
<br />~~'~'G.U~i+IT ~~C#SS \%F~i...U AEal11REMENT>~
<br />~ ~~!!~~# ;.~t~qA fii)r DA~i_1~` 1`'!X ~'~4fi;..
<br />
<br />NAMErTITIE PRINCIPAL EXECUTNE OFFICER t
<br />anuy u cr Pena ty o law that Ihb docoment and dl attachmenb were
<br />prepared under my dlreciton or supervMon In aaordance with ~ syrtem desl`ned
<br />A
<br />TELEPHON
<br />E
<br />DATE
<br />/^~ /^
<br />//~ ~~ ~ / .,, ~ ~p! S to assua that quaNRed personnel P~~y ether and eraluale the Intonnallon
<br />submitted. band tm my Inquiry of the person or persoro who mana`e the system, \~~~
<br />~
<br />` ~.J
<br />{ /' or those penoro directly mpornibk for plherin` the Information, the Information
<br />aubmltted Is. to the belt of my knowkd~e and bedef, true, accurate, and complete. `~'~
<br />' J~ 7!~ /~
<br />~/ v - l~(/~/ ~y
<br />~ ~i
<br />/
<br />/~
<br />~~
<br />r q/ ( ~ 1 am aware Nat there as slEniflunt penaltla for submlttln{ hhe Information EIONAT~IRE OF PRINCIPAL EXECUTIVE CCCJJJ VV
<br />TYPED OR PRINTED ,
<br />Indadint the pomlDluty of arse and Imprisonment fw knowln` ddaUom. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANA 1 IvN yr An r vw~rt t tuna irt~reimce an ~rwcnmrrnia neie/
<br />T~~ ~t T'f~Tr~~. ~~~~ LZE'iTT~ s~:~~ly r~ ~~aA~~~O, ~~ 5.~6T~~~~L.lt* sa: ~~~ Lxi"d~T AiaP~.i~LD ~~Q~ <~=~ov>~,~~i-a~ i~R~~I~ ~~~iv~-
<br />~zr~ ~Ui~n~l'~ ~~ ~r~c~a~ i~~~U~r~~i•~~i~ ~ a U~~~~ ~. ~•~. ~. T ns i"IC)I~IIT~RIiait~ - :~. ~. ~.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. f,~C1 ~, ~9 / O~~)~~' ~~~Q~. PAGE ~OF
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