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PERMITTEE NAME,`ADDRESS Una lu~k~ Fucilily Naruc'Lucmion llt7iffercnq NATIONAL POLLUTAM DISCHARGE ELIMINATION SYSTEM (NPDE$) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS - <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />• FROM TO <br />Forrn Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER t]UANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE ' <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />' _'r PERMIT - r 'LJ f.Cl=! ! T `~j ,G <br />~, tj.nt- ', _; t,J.G,I Ivlt REQUIREMENT i^!:3NTti <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 cemfp mtdcr Ixnnln" of law thm this d,xurtxnt and au anachmrnt`s acre <br />• <br />d TELEPHONE DATE <br />_ <br />_ / <br />~ -~-"-" tih a system <br />prcparnl under m~ dvecuun nr supra Sinn m accordann u <br />rstgned <br />to assure thus qualiticd perx,nncl proptrlc va,her ~md e~-alumr thr mlimnntrem <br />~ <br />, <br />~~c`- ~ ` L- `~~ -~ •~` ~ uin~ of the person oc persons w~hu rnanngc the system <br />submiucd <br />Based on ra <br />m - -~ - <br />- <br /> . <br />. <br />p <br />y <br />or those persons dtr-ctly respon.,ble for gathumg the m(i nnanun the mformanun ~- ~ ~ ~^ -> ~ <br />'-~ ~ <br />r_ „ , /-, ~:I s d,mtt d - ~ th ~ Ix,s f n:y S.n ~ledec n~t }uh •!. tr r ~.nnt r 1 ~nm ,t.,t~: <br />I <br />., <br />I <br />I <br />r i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- °~ > <br />• <br />y _, <br />~ ' i'. <br />' <br /> - <br />, <br />~ .: <br />~n, <br />~, OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR <br /> <br />TYPED PRINTED <br />~, :.;:, ,. ~ ,.. ~ <br />~ <br />cooE MO <br />DAY <br />GUMMtNTS AND EXPLANATION Vr ANY VIULAf1UN5 (Helelence all arraCnmenlS nereJ <br />EPA Form 3320-1 (Rev. 3(99) Previous editions may be used. <br />