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PERMITTEE NAME/ADDRESS pnclude Facility Name/Location if D[Jfereny
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<br />• Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB NO.2040-0004
<br />. DISCHARGE MONITORING REPORT (D R) :.*;:.'i~;..i~'C
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<br />PERMIT NUMBER DISCHARGE NUMBER - ~r ,. i'i'i'r' _ ~~I"-~ P'
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<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY °"
<br />FROM 6t. :c:. 't:' TO v, 1 _t .,z ~ ,;:~• i•:~:' L~T~~{„-r~~~~i_ ! ~s.•; r•tti•.N.
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER l certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br />to assure [hat qualified personnel properly gather and evaluate the information
<br /> submitted. Based on my inquiry of the person or persons who manage the system, ~,
<br /> or those persons directly responsible for gathering the information, the information / /~) /
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<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE 9
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<br />/ I am aware that there are significant penalties for submitting false information,
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<br />OFFICER OR AUTHORIZED AGENT AREA
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED at
<br />ons.
<br />including the possibility of fine and imprisonment for knowing vio CODE
<br />COMMENTS AND EXPLANATION VF ANY VIOLA I IuN, (rrererence au arracnmenrs Here/
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ; 1!+r•:~ , ,-,'~''171~'1$'a 4- aiC:fOI1T1. PAGE
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