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PERMITTEE NAMEIADDRESS rlncMdcFacilln•It4rmc2<uartnrr tjDijjtnrnr/ <br />NAME <br />ADDRESS <br />FACIUTY <br />,;; i <br />LOCATION _ _ , Y i3 7 <br />r ~ :~I ,- ni.-.. .]i. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <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 Approvetl. <br />OMB No. 2040-0004 <br />~, / <br />NOTE: Read Instructions before carrlpleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREGUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE • <br /> <br />-• MEASUREMENT <br /> PERMIT - - -, ~- , > - ti ~, ''r.) ~ I:. ~, ~. <br />,- i.I _ REQUIREMENT ~ ' 1:~: -"'~ AV rn_., ; .. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , ~ ~ . , >' ~.J t ;_ :. ' t :'~ f t <br />`.);_i~! ~ ~~, ': _~ V.~+_.;~,~. REOUIREMENT iii . ~"ILP•i 1-H <br />- SAMPLE <br />r- ~ t,•r; ;. ;, MEASUREMENT <br /> PERMIT ~ ; i/ .~!'hl <br />:.-I r, - ,^.. ( r !' REQUIREMENT Ph71+~ T'` r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />;.,j ' _ .. REQUIREMENT Y f'3 .;: !+ir]r`-~-y , <br /> SAMPLE <br />~ ~~ = MEASUREMENT <br />- - ~ PERMIT 7 f~ LJ ? :''= / rftAB <br />- ._ REQUIREMENT ;"~ ~'`,'C; f•,~. , ,..7 ,.- <br /> SAMPLE # .r -~ x <br /> MEASUREMENT <br /> PERMIT w +, _t ., r ~ ~ .~ ; : nldT i ~l i.`` ~? i <br />- - i _ ~ _ REQUIREMENT . - -' ; 1' <br />'. SAMPLE r. .. ~~ ~ .. <br />r.i MEASUREMENT <br /> PERMIT - „ . r ~_ , !•~<' ! /~. <br />- REQUIREMENT ~ ' ' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I urtif~ under peonln of law that this dcwument and all atuuhmcnn acre <br />~ TELEPHONE DATE <br /> <br />- --^ ith 3 svacm de~~sned <br />prepared under me duecnon or sulxrvision m accordance H <br />_ <br />Sere ! ~ (~~s> <br />y'>E i <br />- to avute that yualifin! {><•rxmnel pru}xrly~ gather arxf c~aluatc the mformau~n _ <br />- <br />~ <br />, submitted Rsad on m}• inywn~ o(the peturn ar pennns whu manage tlx system. ~ <br />- ~ <br />~' <br />~ <br /> ur thcne pmons directh~ rnponsrble for gathenng the mfommnnn. the information _ <br />- r. - ° " <br />- - <br />~ <br />~ ur <br />om <br />f+ <br />itt <br />l i <br />th <br />h <br />st <br />f m <br />kn <br />wl <br />d <br />d b <br />li <br />f <br />ira <br />te <br />and <br />lee <br />t "' <br />~ ~ <br />/ t ~! <br />~, . o <br />o <br />e <br />ge an <br />e <br />e <br />, <br />te. acc <br />a <br />, <br />c <br />p <br />su <br />rn <br />a <br />s, <br />e <br />e <br />y <br />o <br />t th <br />t <br />lu <br />tu <br />tul <br />I <br />th <br />i <br />f <br />f <br />b <br />C <br />u $IGNATURE OF PRINCIPAL EXECUTIVE ~l j ~. 2 <br />/ :., <br />~ G C. ~~ f ~ <br /> <br />TYPE OR PRINTED ere uc s <br />ican <br />pcoa <br />or su <br />mt <br />yc m <br />on- <br />am aware <br />a <br />gni <br />cs <br />ng <br />orma <br />ih <br />fi <br />C n <br />t f <br />k <br />i <br />l <br />d <br />di <br />h <br />d OFFICER OR AUTHORIZED AGENT AAEA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> nr <br />nowing r <br />ty o <br />ne an <br />unpnummen <br />o <br />ah°n, <br />m <br />u <br />nq t <br />e Ixss <br />r CODE <br />I.VMMCI`1la tt+1f`IU CR1't.f\IYtri11V1\ Vr N[v7 vrv LNllvt~J tr1CICIOnr:e OII auac.nnrCnta ucr c/ <br />~MPi.I N6 I NSTFr.UC1 <br />EPA Form 3320•t (Rev. 3,J91 Previous editions may be used. <br />