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PERMITTEE NAMEiADDRESS rlnclndcFarUin Name2orarian rfDlj/?.rrnq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />~r~ E:I6~F~ <br />ir•,~~ r•tAra~~e~~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (HPDES) <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 Na. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np. FREDUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />_ SAMPLE ' <br /> MEASUREMENT <br /> PERMIT ~ ,. .r .. ~. r,-~: r-r~ - . . <br />- REQUIREMENT ~ : i t; <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT k ~ x :, k rr : -. .. , i,l F? T - <br />i'•i "` `v'i3ti l;; REQUIREMENT = , : 1 r I•' ' <br />_. SAMPLE <br />i ;? .a ~~ L_ C_ .-'. _~ ~ _ ~~ MEASUREMENT <br />S' PERMIT - - - f-•:, t- c F: ~F~ " <br />•- U~."r •' ,R[~•.?5 '~',~; .' . REQUIREMENT <br /> SAMPLE <br />c.. ; r -- ;: ~:~, f ~„ ~ - ~_ MEASUREMENT <br /> PERMIT ~ ..... - ~ g <br />i! \! ~ _ ,.•.,' REQUIREMENT aCl)r!r: <br /> SAMPLE <br />rl_; r r.,o• - ~ (•,'-!_c MEASUREMENT <br />.- PERMIT - <br />~.-f • • •-•~ 'era. REQUIREMENT <br />- SAMPLE <br />• - :,.,:..:- MEASUREMENT <br /> PERMIT ? '• .- ~ t. - . .. ~~s•~ s: ~: •R~ T j.> i_:. ~ •I <br />~` Vi''J T ,., , _ ... REQUIREMENT ,-•;; . v ~ • <br />_ SAMPLE " <br />"; : ,c, C :' ' ~ ;_ '= MEASUREMENT <br /> PERMIT s :{~~r'!sf? r ~FI''~r~'T "~{~ _ _ <br />- REQUIREMENT ~ DF• <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I .ertifc under pennlh of lau that th,~ document anJ all attachmrnR were <br />~ TELEPHONE DATE <br /> <br />it ~~ r -- <br />l <br />` <br />' <br />" prepared under my directwn or supen <br />icton m a.cardanca wmh a system deagnei <br />to assure that qualified pctxmncl properly gather artd evaluate the mtimmnnrnt <br />~_~~' <br />-_ <br /> <br />L lrs/ <br />i <br />~ <br />... <br />.ubntined Nased nn my mywry n(the person rte perxrns wixr nwnage thz :cdcm, - <br />- <br />~__ _ -- - <br />~ <br />~/ <br /> or those perxms directly resTwaaible far gathering the inf~tmtatian, the information ~ <br />- - - " <br />~~ __ <br />t_ ~~ <br />~-~., submitted u, to the hest of my knowJcilgc and ttchcf, retie. arrtvate, and camplctc <br />I am aware that there are <br />t <br />n <br />fi <br />ant <br />enaltie <br />far s <br />bmutin <br />false infomtation SIGNATURE OF PRINCIPAL EXECUTIVE r <br />~ J ti ~ <br />~ ~ <br />~ - <br />~` <br />' <br />TYPED'OR PRINTED s <br />g <br />t <br />p <br />u <br />g <br />. <br />c <br />s <br />includin <br />the <br />osstbiht <br />of fine and im <br />risanment for knawme vielanons OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> p <br />g <br />p <br />y <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA Form 3320-t (Rev. 399) Previous editions may be used. 1)us IS :i =~-part iOn <br />