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PERMITTEE NAME~ADDRESS rlrrclrule Fuc•rlln• .yume "Locution ij DiB'errnrl <br />NAME .- .-.. ..... <br />ADDRESS '._f-;AD( <br />-, <br />FACILITY - <br />LOCATION <br />~ 1 4F3 <br />APdAT•f-1', <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (1JPDE$) <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 />F - P I P~iAL <br />ACUTE Ld)=T TESTING <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br />OF <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />- - SAMPLE <br />L MEASUREMENT <br /> <br />PERMIT <br />~: ,, ~ <br />is _ _ <br />.. <br />•i `,;_ <br />- ~ <br />>: ; .: ~ <br />: ;,~ •~. -• - <br />~:.. <br />-°-' - - . tt- <br />` 1 REQUIREMENT ~•'~ i'lr - <br /> SAMPLE <br />• t;',:_ : MEASUREMENT <br />- PERMIT .- - <br /> <br />~,I r - :jr_, _I, n 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/TITL.E PRINCIPAL EXECUTIVE OFFICER I :erpf} under penalty of law that this d~xumcnt and all attachnxnts aarrc TELEPHONE DATE <br />_ prepared tinder m9 drrectron or suprnision m arcorrLutce with a sti•;tem desrened <br />/ -~ to .castor tiwt qualified personnel properly gather and caaluah• the m(i~rm:uion <br />S <br /> <br />.-o~ lva ~~f ~ ". (~~ submits •ai ftaacd nn my myuw of the pentm or persons who manage the sgRem. ..--~~' <br />~ ~ <br />/~ --~-~ " <br />rm rhos prrwna drrecth recprn.ibk for gattxring the information, the information ~ <br />••~+~~ <br />~ -~~ , e. •i avbmincd i>, to the best of my Imowlcdec and belie(. true. eieurete, and complete <br />t <br />f <br />h <br />( <br />h <br />ia <br />h SIGNATURE OF PRINCIPAL EXECUTIVE ~ ~ j -. ~ ; <br />~ ~ c- ! ~= "~ <br />~ Y <br />or su <br />mnnnc <br />sc m!onnn <br />u~n. <br />at them arc sr¢nr <br />icam pena <br />te. <br />1 em aware t <br />TYPED OR PRINTED includingttxpr~ssibitin nffinc:utdtmpnwn~tent r;~r:a~~•.~~~~t:.~.~!:~~:~~n~ OFFICER OR AUTHORIZED AGENT ARE:. <br />~~,r~E NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (rYeterence au attacnments Here) <br />- ~ ~ DI:Ri <br />EPA Form 3320-1 (Rev. 3?991 Previous editio <br />~EPtIR?- l C50 - STATISTICAL POINT EST IMAI <br />~)~e -~:~ , ~,.Thl$ 1S il -l-~IBR ~OI'TII. PAGE <br />