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PERMITTEE NAM&ADDRESS ibrclurk Frrc•ihq~ Nrune/Loc-rrrina i~Dr(jnvrll <br />NAME <br />ADDRESS '=~~tf~U~ ~~1C~j <br />I Y <br />FACILITY ~ <br />LOCATION <br />,l•. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDESJ <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 Approvt'd. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions Uefore completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np, fREOUENCY SAMPLE <br /> <br />~ OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />' SAMPLE ' '" '~ <br /> MEASUREMENT <br /> PERMIT ~ - ,. .. ~~ ,' "W ~:.c/ ¢{,_;;: <br />- REQUIREMENT - - .. r•tr''~7'T, f <br />' SAMPLE :- i •' <br />., ~ ~_ ; ; . MEASUREMENT <br /> PERMIT c ^~ :: f ':F?.`-'•L~ <br />F ~ L 'J_;17 r 'v'r=L.'..• REQUIREMENT 3C:': ~ : i - <br />. _ SAMPLE <br /> MEASUREMENT <br /> PERMIT „-:_..._..::: r _ <br />' i =i '.!i_,;." 'vraL`.' REQUIREMENT '.1:-~ .; -r ;.. <br />r- ~ ~ SAMPLE <br />r - ~- MEASUREMENT <br /> PERMIT ~. ,_ ,_ ,•. x. : r - . <br />'~ ;: t'J : '/+ai_'. REQUIREMENT <br />• SAMPLE - <br /> MEASUREMENT <br /> PERMIT .. .,- ~ ~.*: .; ~ :::' . ., ,; x ~• f 01 'Rfit~S <br />,_" t, . ~ REQUIREMENT . `.. i •: <br /> SAMPLE ~~:3 ; ~- <br />i ~ - _, r - MEASUREMENT <br /> PERMIT -';_, ._-. •!' F'.. '''?c., ;•i°:r: r. ~s~tr~•~.'•i-'- s, -. t ?T;' :. •„ <br />'~F ~ ~: .. - _ - .',~ RECUIREMENT - - ,;. .. <br /> SAMPLE ., t °:r <br />;_. MEASUREMENT <br /> PERMIT , f ~ ~.::r- r :, !-~/=f}r~~7 REPJRT <br /> REQUIREMENT `~ r-' ~A 7 (_ Y t ' ~' <br />NAME/TITLE PRINCIPAL EXECUTIVE O FIFER I crmfj undcK Ixnalty of lu« that this drxvment ;utd ali atu.hmrni wrrc <br />J <br />di <br />ti <br />d <br />i <br />i <br />l <br />i <br />h <br />d <br />i <br />d <br />- TELEPHONE DATE <br />~ <br />/ un <br />nn or superv <br />ance w <br />pn <br />pvc <br />er my <br />m <br />s <br />on m aca>n <br />t <br />a s}stem <br />e <br />gne <br />f ~ <br />~ <br />,~~ <br />Grnt.SJ~~ <br />G / to assure that yuuli <br />ial Prr~~nnd pro~rty gathcK uruf cs~aluaec the intlrmcuurnc <br />b <br />in <br />d <br />B <br />d <br />i <br />~ <br />f th <br />h <br />h <br />t _ _ <br />_ <br />/~ =~ <br />' <br />~ <br />~~^ <br />' <br /> c <br />on my <br />e person or tx:nons w <br />su <br />m <br />. <br />ax <br />nywn <br />o <br />u manage t <br />e sys <br />em. T <br />/ <br />' <br />- <br />- <br />~ _ / x those prrscros duuch respmcschle for gnihnmg the mfortnauon the inti~mtanon r ~ <br />v ~ ' <br />y <br />iy ~ -, ', - submittal is, to the lies[ of my knowlaige and belief, rnce. accurate, and cncnplrtr' <br />1 ant awnrr that char uc st <br />mficant pcmalncs for submunn@ taLu infnrmaum SIGNATURE OF PRINCIPAL EXECUTIVE - --~ y~ „_' _ <br />+ ` _ -~' S <br />TYPED bR PRINTED g <br />. <br />including the pussihilit} of finc urxl impnummcm for Lnowcn~ ti,olmion. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> CODE <br />wmmtrv IS ANU txYLArvs-I Ivrv yr Nnr vtvu~l Ivrva inererence au aaacnmenls Here/ <br />"- :R R^ <br />EPA Form 3320-1 (Rsv. 3199) Previous editions may be used. <br />PAGE OF <br />This is a 4-pare forni. <br />