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PERMITTEE NAME.~ADDRESS ~lncfudeFrrcilin•Nwru•,~L.xariontJDiJjc~xnrl <br />NAME <br />ADDRESS ., <br />4 j <br />FACILITY <br />LOCATION r ;_ {_ <br />1 ~ 1 i 1 :'a; % i ~ . P•t 'i IVF' MAti!, <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />M I fVLIR <br />{ SUL;i? i~W <br />NOTE: Read Instructions before completinG this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, fREDUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ ~=r ; ~ ~... <br />~•j~-r~ MEASUREMENT <br />' _ PERMIT ~..t.~.,. ,t .. r-t ?t#••r .. •... -I;a' I'-: ~ / J: ;~VAt <br />• ~ _ ~~ ~ :' REQUIREMENT r': 'f I rH <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 />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I ccrttfy unJrr I><•rshy of law that This akkumenr and all anarhmcnt. wrrc <br />areJ unJer rn. Jrr <br />e with <br />rc <br />rainn or <br />u <br />cn~ <br />ion <br />ac <br />o <br />J <br />n <br />ac <br />d <br />i <br />rn <br />l TELEPHONE DATE <br />. ~rO ~. j - <br />'n.~ ; . <br />~~~ p <br />p <br />e <br />s <br />p <br />ts <br />m <br />e <br />r <br />a <br />a sc <br />c <br />m <br />es <br />g <br />a <br />to nssurc that yuahfieJ personntl properly gather anJ evaluate the mtormaunn <br />b <br />m <br />d <br />B <br />) <br />i <br />f th <br />h <br />h <br />- <br />am' <br />- <br />. on my <br />su <br />m <br />e <br />- <br />ase <br />ngwry o <br />e person or persons w <br />o manngc t <br />e ,ystcm, r <br />i y <br />~ <br /> or those persons directly rc~spanutblc for gathering the mfonnauon. the infi>mranon ~' ~ <br />_ <br />`-.~r ~. ;.- ,. .- suhnunrd ts, to th h't n(m n na ledc ut t fx.~r! n ~. :xc~ir- r mJ r~~niplrk- <br />• <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~ _ ~ Y -' ~ - <br />a.' ~:~ <br />-> <br /> _ OFFICER OR AUTHORIZED AGENT AREA 'i N <br />R Y <br />TYPE OR PRINTED <br />- -- ' r ;~,- <br />- --- - - - ---- UMBE <br />CODE EAR MO DAY <br />GVMMtN 15 ANU tXl'U4NAIIVN Ut AIVT vIVLJaI Iona tnererence an arracnmenrs Here/ <br />IR pPt <br />- ~ - - - _ _ ~ SAMPL <br />EPA Form 3320-1 (Rev. 3139) Previous editions may t <br />