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PERMITTEE NAME/ADDRESS Ilndudr Fuilitl• :~'oMr/laratinn if LiffrrrnJi <br />NAME <br />^i, Ftilji: <br />ADDRESS ~% <br />-- ~- 4,a7~D • : ~ ~ t <br />FACILITY ~, r} i f4j,Q <br />LOCATION <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 />IY <br />~; <br />F <br />R lJl <br />Form Approved. <br />pMB No 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />5~- -}~ <br />5S I ~ <br />~ <br />I) ~ <br />~~CZi18 <br /> MEASUREMENT <br /> PERMIT r .., - _ .. y :. ~: <br /> REQUIREMENT ~ 'AX <br /> SAMPLE ~• ~r <br />~ <br />~ <br />~> lI~ <br />_ ~ <br />~ I <br />'~'•'~ <br /> MEASUREMENT ~ I - <br /> PERMIT ~ ~ f<;: , ;, . _ . ..: ,: <br /> REQUIREMENT ~ , i-1A r <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 certif. under prmvil~ of law that lhis durumrnt and all atwchmrnb weer <br />re <br />ared utuler mr dirniion nr m <br />x~n ision in accordance with a cr <br />t <br />m d <br />si <br />nrd _ / TELEPHONE DATE <br /> <br />~ ` <br />_ <br />\ ? <br />ik r; ,i./ ~ ~J p <br />p <br />t <br />s <br />e <br />e <br />P <br />to aswrc that ywdllfrd Ixrwtnnrl proprrk Kuthrr and eaalmlr tlx• Information _ ~ <br />I <br />V ` <br />1 <br />~ <br />!-x~` / "`~"-1 l-- • <br />iu <br />f <br />R <br />xd <br />f th <br />b <br />i <br />i <br />h <br />Ih <br /> <br />1 u <br />m <br />n <br />. <br />nn m~ <br />nyu <br />n o <br />e person nr prram. w <br />o manu>;e <br />r s.+irm, <br />+ <br />nr Ih~wr prnnxa Airccth n•-.pmsihlc for kuthrrinK th< inlormation, t!x• in(ormntion _ <br />~ ~~- <br />~ <br /> <br />~ <br />- <br />. <br />~ <br />suhminrd i., m the Lot of m~ knowkd~e and belief <br />true <br />accurata and camphyr f <br />•? '• <br />~ `~ 1 j (~ <br />~ <br />L~ ['j <br />LI ~ <br />~ <br />_ <br />• <br />~ <br />' ~ ~-' . <br />, <br />. <br />w <br />I <br />e th <br />t the <br />i <br />iric <br />m <br />itti <br />tN <br />e <br />• <br />lti <br />f <br />b <br />Gd <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE ., <br />! <br />L~ -~ <br /> ~~m a <br />ar <br />a <br />arr . <br />{In <br />q <br />nu <br />or wt <br />ng <br />n <br />nrma <br />m. <br />r <br />u <br />rs <br />m <br />cr OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED inrliulinK Ihr posihUN~ of tint and impriamment rnr kmtwink aiolalions. NUMBER <br />CODE YEAR MO DAY <br />GUMMtIV15 ANU tJ~F'LAIVAI WIV Ut ANT VIVLAIIVIVJ Irreverence an aaacnmenrs nere~ <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. - T}lIS`tS d 4-~1aI'f Pflrfil. PAGE OF <br />