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PERMITTEE NAMErADORESS rlnchelC F.xelin• wrrreciL,H~ur;on,Jnjjcrcnq NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NFDE$) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS , ;_~t <br />-*-~~ PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION . - , YEAR MO DAY YEAR MO DAY <br />FROM TO ._ <br />Form Approved. <br />OMB No. 2040.0004 <br />:WfsUE "~r~Ei~~i'M~I <br />~~ _~~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np. • FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />. = <br />• <br />r SAMPLE <br />MEASUREMENT "-, <br />, } G-' ~ , I <br />~ ~ <br />~ // <br />~ 7 ~, <br />~ ~ ~ r <br />L '~ L' <br />` <br /> <br />l (:) <br />:: <br />V , <br />~' <br />C_,o , <br />yf~ ~ <br />;: - ~ PERMIT _ .: ~ _j - f .M1lCI~! ~ - <br />'r. •'•'•: _~i- W... i !ENT REQUIREMENT f"fJ~t"i'F' <br />I ' SAMPLE <br />/ <br />r; t=:" r t i ,°'. ~ MEASUREMENT ~- <- <' ~ ~ i ~. ~ '.-" , . <br />_. c. -. 7 PERMIT I: r F'tJf-~ ' C• r < : -u ~ , ~ ,z ii-;x##tit# 'T1r a r fd~~:= / "-i i~r~N' <br />F'Lt.r-rv . '='10;55 .. REtUIREMENT i ~ •.' I'I MOIVT~'. <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 crmfy under penait}' of law ihnt this docttrttmt and au attachmenn were TELEPHONE DATE <br /> <br />~ <br />~~ - prcptttcd under my dtmcuon of suprn~utnn in accordance wnh a system destgtted <br />_ <br />J l U~y L- ~ ~ 9 to assure tluit ytwlificd pen;.:nnrl properly _aather and evaluam the mf~mt:num ___ __ <br />~ ' _. <br /> submitted. Bawd nn my inyurry of the prrson or persons wtw rrranagc the system, ~ <br />~ <br />~~~ <br />~ ' <br />,~ or those per5otu duw;tly resputuiblc for gathering [he information. thr mlumtaGon ~ <br />-- <br /> <br />(--• ~ ~'i%~: <br />submited is <br />to the first of my knnwirdgc and belief. tnu. as orate and armplcu <br />"' . <br />~ <br />~ <br />/ _ <br />{ <br /> , <br />- <br />am aware that there are significant penalhr; G•r ~uMnnnnr i.~h~~ a»~~roitdi~ <br />~n SIGNATURE OF PRINCIPAL EXECUTIVE .,/ ;• 7 <br />- C }~- ` <br />.~ ~ 7 <br />"! - <br />TYPED OR PRINTED . <br />. <br />trrctudirg the possibility of tint and nnpriumm<•r ~.,- kc~ ~. ire . i~?:eID,m OFFICER OR AUTHORIZED AGENT <br />. AREA NUMBER <br />CODE YEAR MO DAY <br />IiVMMGI`I I J NI`1U cnr-{-'+1~'+r lvn Vr nn r <br />EpA Fprm 3320 ~ fRev. 3,'39) Previous edRiors ma <br />YI IVI~J tl1CIC/CIII.C OI/ O{l0[iI1l IIC11{J lICI C~ <br />?RTED P/1CNTHL Y REGARDLESS OF WHETHER AN Ei <br />ffiis isa l-nail form. PAGE OF <br />