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PERMITTEE NAME/ADDRESS pnclude Facility Name/Location if Different)
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<br />FACILITY -:~-f;~?.;:s :~ti~t. _ 1J~s•:
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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°, , y;~ ~r2
<br />PERMIT NUMBER DISCHARGE NUMBER •-' ~ t'}=~`' .
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<br />FROM '., r .~.: t. ~ TO '_', .. ~.t t .~ }'3,_ ..:.. , r" ).~
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FRenueNCY
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER f certify under penalty of law that this document and au attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br /> to assure that qualified personnel properly gather and evaluate 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
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<br />/E I am aware that there are significant penalties for submitting false information, AREA
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<br />(/ I TPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT COD NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY vIOLATIVIVS (f•fererence au arracnmenrs nere~ ^- ~ u `
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<br />PAGE =•.OF
<br />>; .'°~;'••'?.r' x::"Pltis'i~ ~a 4=p~r•E:ftrm.
<br />i EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. - ~ ~'
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