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PERMITTEE NAMEIADDRESS ilnclude FaciGh~ ~ame!locatinn iJ(hJJrrenq <br />NAME <br />ADDRESS <br />.1 lii_ ,a ~ _ i~~1 <br />FACILITY r_r,) Glli..CH !..Ur~0E1VT <br />LOCATION ~ N r ~ ~-] <br />A~! F'. UUNf~1=~ D2:RFCTGR <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. 2040-0001 <br />r <br />~~~. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION rJQ- <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 /> 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I aenir> under pennllp of law that lh;a d~R'n0lenr and :dl atwabmonra werr <br />i <br />ith <br />d <br />di <br />• <br />i <br />i <br />; <br />d <br />t <br />d <br />i <br />d <br />- TELEPHONE DATE <br /> o aaror <br />ance w <br />u s <br />em <br />ea <br />gne <br />pnparc <br />undar m. <br />n <br />t <br />un or aupen <br />a <br />nn <br /> rn aamre Ihal qualified perv~nnel properly ¢alhrr and ea aluulr Ihr MGirmWion <br />. <br />~ <br /> whmitled. llaard un m. inquin of the Iw•raon or ra•rvma who managr the yvem. i <br />, <br />/ <br />\ <br /> ..r Ihaae persona dimcd~ re+p~miMe for quthrrin~ rhr inGrcmauon-the information / ~- - <br /> .ubmiued h <br />In the beat id mt knowledge ar~d Ixlief <br />Irne <br />aca-uraR <br />sad complete. / <br /> , <br />, <br />, <br />, <br />irti <br />ti <br />I <br />h <br />; <br />r <br />lli <br />f <br />b <br />f <br />l <br />i <br />f $IGNAT{1RE OF PRINCIPAL EXECUTIVE -' ' <br />' <br /> <br />TYPED OR PRINTED or su <br />a <br />on, <br />um aware that A <br />ern ure a <br />Rni <br />u:+nr prna <br />ca <br />m <br />nK <br />ce <br />n <br />orma <br />;ndudi P R, <br />nK the p~nsibility of fine and im riaunmenl for km~win ioluti~a~s. OFFICER OR AUTHORIZED AGENT i <br />, AREA <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t (Rev. 3199) Previous editions may be used. Tots ie d -~-p <br />