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PERMITTEE NAME/ADDRESS Ilnrludr Fw~ifirv ,`nme/Location ijD1,Q'nnul <br />NAME <br />ADDRESS <br />~~a <br />i {, Q <br />FACILITY . ,:jQE.}'I- <br />LOCATION ~ "y C ~ <br />~iiV !' GI.,'NF-t:E, J i Ft~r TCJI~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION ND, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT •• .. - .... , <br /> REQUIREMENT " ' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />R <br />Q <br />I <br />T <br />' '' <br /> E <br />U <br />REMEN <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~~ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT `~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br />NAMElfITLE PR E OFFICER { arnit> under Ia•nulh of law that this d~avmrnt and all attarhmenls were <br />d <br />di <br />with <br />d <br />d <br />[i <br />i <br />i <br />i <br />~ <br />~ <br />d <br />i <br />d <br />i TELEPHONE DATE <br /> prcpnre <br />on or wiper <br />or <br />ancr <br />r ss~ <br />rm <br />Rnr <br />un <br />er mi <br />m <br />s <br />nn <br />n na <br />a <br />es <br />e.f' <br />~~~ to axsurr That yuulitSrd perwmnrl pnyw•rh Knther amI ea aluate the informuliwn <br />N•rsed on m <br />uire of the <br />ervm or <br />rrsons who mnna(te the c <br />whmittrd <br />in <br />stem <br />~ <br />- <br />~1 <br />5~ . <br />y <br />q <br />p <br />p <br />. <br />~ <br />or those person. direeth recponsiMe fwr RathrrinR the information. the information , - <br />. <br />~ <br />~ <br />` <br />' whmiaed Is, to the tw.t of m~ knowladpr and Iadkt, trur, aerurato, a~ c~wnplctr' <br />th <br />t th <br />if <br />t <br />lti <br />itti <br />i <br />I <br />i <br />f <br />h <br />f <br />{ <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am aware <br />ere are s <br />Kn <br />es <br />ur wi <br />m <br />nK <br />n <br />ormat <br />on. <br />a <br />ican <br />pena <br />a <br />sr <br />irkludinR the possihilih of one and impriwroment for knowinX siulatiom. OFFICER OR A1lTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachments here) <br />EPA Form 3320-t {Rev. 3+99) Previous edirions may be used. <br />This is a -1•-Part form. PAGE OF <br />