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PERMITTEE NAME/ADDRESS tlndud~ Ftuiluv .\'ame!lluutiat iJlhffrrrnq NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY ;l ~~ MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />LOCATION FROM TO <br />car;..~ ,> ,~ <br />Form Approved. <br />OMB No. 240-0004 ' <br />CHkCt~l? ~ WE'T T1^ST I NG FUR 004A <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />,~ c ~ <br />I. <br />s . <br />_. ~~.~ <br /> PERMIT <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x ``-. ' <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 />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I +'''rtit+ undrr prnulN of law Ihul Ihi+dr~rumrnt and all utturhmrn~ wrrr ~ TELEPHONE DATE <br /> prrpand umlrr me dirarlion nr +upa•n i+iun in uarurdancr with a +slcm dr+i¢naYf <br /> In a++ure That yuulifirtl prr.rnutrl prnprrl~ gathrr and e. uluam Ihr in/urmatirxt <br /> +uhmiuad. Ru+ad nn m. inyuin ut the penun nr Iw,rwm+ whn mana>;r Ihr +~-+tem. <br />..r thw• pa•nun. Aine•tl~ rr+prn+ibla• fur t;utherinyl the intnrmaNun, the inturmutinn ~ <br />^~ <br /> ktr <br />G <br />f <br />d - <br /> , Iruc. nccurutr. utt <br />comp <br />. <br />whmittad h. to Ihr he9 of m~ knowirdRr and In• <br />c SIGNATU OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware Ihul lhrre arr+i}pnifkam prnultir+tnr+uhmiUinK fal+r informatiun. <br />inrludinL Ihr w+ihility of rirtr and im rio-onmem frir Lmrwin +iulatirxn. <br />w p l: OFFIC R OR AUTHORIZED AGENT AREA NUMEIER YEAR MQ DAY <br />GUMMCI`JIJ AIYU CAr'LAI`INttvty t/r NIY7 vtv~ntwn~ Incn:v c+ra,t: an auownnmrm .rc. c~ <br />r-..r-rar o r~cnnrd4-~. nco TIIATTPIAIC AC "Tr11 <br />PAGE OF <br />EPA Form 3320-t (Rev. 3/99) Previous editions may be used. T'hi~ is a ~#-part'fhrn~. <br />