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PERMITTEE NAME/ADDRESS tlndude Farilih lamr/location iJ/)ifJere~u; NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDESJ <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />~- PERMIT NUMBER DISCHARGE NUMBER <br />E! <br />FACILITY •, CFi f 1 ~d'c. c:i~rir. : MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />EN i; O 81 E...: FROM TO <br />bCRF2U, RFCLAt'Ir~T FON MANAGER <br />Form Approved. <br />OMB No. 2t~0-0004 ~ <br />iC~-IARGE TO SArE i~RFEI~ <br />~LlI_Ir~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FRE4UENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />- /.~ ~ ~ ~~ ~' <br />-' <br /> MEASUREMENT -- <br /> PERMIT " <br /> REQUIREMENT ' `' <br /> SAMPLE <br />. ~ <br />~ <br />; <br /> MEASUREMENT . <br /> PERMIT ~~'_-~ <br /> REQUIREMENT ~ ~ <br /> SAMPLE <br />~ " <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 1 certifi under penulq of low that thi+d~KUment and all ullttchmem. werc <br />with a <br />+t <br />d <br />d <br />r <br />dl <br />ti <br />n <br />n{ <br />lo <br />in <br />o <br />d <br />n <br />m d <br />si <br />n <br />d TELEPHONE DATE <br /> prepare <br />un <br />e <br />m? <br />rec <br />un <br />r supe <br />+ <br />n <br />acc <br />r <br />a <br />ce <br />sy <br />e <br />e <br />g <br />e ~ <br /> to a+.curr that yualifled perumnrl properly gather and e.ahwte the Information <br /> +uhmlitnl. tia+rd nn m? inyuin of the pcnon or pcnun+ who manage thr s?atm, 1-_~ ~ '~~ - _ <br /> or thn+e persona directly responsible forgathering the information, the Information ~ _ <br />~ j <br /> wbmittad i+, to thr be+t of m+ Am~.~la•dge and brlirf, trur. ecrurate, and rumplrte. <br />t <br />h <br />.i <br />iG <br />l <br />i <br />h <br />itti <br />i <br />ui <br />I <br />h <br />f <br />f <br />l <br />G <br />SIGNATUJiE OF PRINCIPAL EXECUTIVE <br />- ~ ~ t I <br /> <br />TYPED OR PRINTED am awurr t <br />rrt arc <br />ar <br />ar ~u <br />m <br />ng <br />u <br />n <br />~rtm <br />a <br />t <br />gn <br />wm penx <br />t <br />sr <br />un, <br />includin the thibn n! fine and im n.nnmcnt for knmain i lutiom~ <br />R p~r~ p g a ~~ OFFI R OR AUTHORIZED AGENT AREDE NUMBER YEAR MQ DAY <br />COMMtNIS AND EXPLANAIIUN Ur ANY VIVLAIIUNJ (liererence all aRBCrlmenrS neIBJ <br />:: D'S LT.MIT APPLIED FCIk •~=10YR, a4HR PREGIP EVENT. TSS, <br />_ -'4t-IR PF~EGXP EVENT SUDJECT TD BURDEN OF PRODF IN I. A 3. <br />EPA FOrm 3320-1 (R6v. 3/99) Pfevi0u5 editiOftS m2y b0 uSBd. '.)I~~Ic ~i1S.iS 3 ~-~Sft fntlll. <br />