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PERMIT'~frK NAME/ADDRESS ~/ndade F'aciGtv.lamr/!.xatiun iflliJ/amp <br />Ni4ME L `- <br />ADDRESS - <br />'1 :~ QUIVT Y ROt`-•D 1 Ott <br />FAClurf ~ COAi_ iK.TP4E <br />LOCATION ' F ~ US C l~ <br />~_I`I7 PE~cRSON, rRE::I ~EW~' <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 Approved. <br />OMB No. 2040-0004 <br />~LTI-` <br />I~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT : '~ - - _ <br /> REQUIREMENT •• - , 7. i fIUM <br /> SAMPLE " <br /> MEASUREMENT <br /> PERMIT ; r r::_• <br /> REQUIREMENT ~ ` ~ r ~'' ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ., 4-- _~ <br /> REQUIREMENT G ,/ -'r-'j-'`~ A4'C: , <br /> SAMPLE /~ _ _ <br /> MEASUREMENT r ` <br /> PERMIT ~ :> .. - ~ r _ . -. .. . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT lJ <br /> PERMIT •" ": ~ ._ _ _ <br /> REQUIREMENT __ ~:'~-. h'.'G ~ . ~ % ;•~i '•.f i ! i <br /> SAMPLE - .. - <br /> MEASUREMENT <br /> PERMIT ... _ , . .. _... - <br /> REQUIREMENT ~ C' i" <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - _. -- , .. .. - ,..... ..._ .. : -_ <br /> REQUIREMENT (..., _ t ., . <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l ccnir> ondrrla•nalu ,d m» that thi+d~rumem and a0 attachmrnt+wrre <br />e <br />ared <br />der <br />n dir <br />•tH <br />• <br />i <br />i <br />i <br />• <br />l <br />i <br />h <br />d <br />d TELEPHONE DATE <br />~-~%/ ~ ~ _ - <br />• - p <br />un <br />n <br />ea <br />m ur wp <br />n <br />un <br />a n~+trm <br />pr <br />+ <br />un <br />n w+~ <br />uncr w <br />t <br />rlgae <br />to mrure that yualifi d prr..mncl pnga~rl~ guttter and realuatr the InfurmaWm <br /> +uhmitted. Rx.cd un m+ inquire o! the prrwm ur prr.,m+ whu manage tiff q-+Yem. ~ " -- <br />~t <br />/ -~ _ <br /> ur [hirer ptaon+dirtrtt~ rr.+la,mihle fur gathr,ing the informatMm. the inGa•mation ~- <br />~ - <br /> +uhmittcd h. to the hrt of m~ km~a kdgr and I,rlirf. true. an~urate. and cumpkm. <br />I am aware that there are+ignificant tx•naltiRlor+ubmiuinglalse informaUm <br />SIGNATURE OF PRINCIPAL EXECUTIVE -. - ~' <br />~ - - ~ (. `3. J Z J <br />J <br />TYPED OR PRINTED . <br />including tree pnsihiliy .,! fine and impri+unmrnt f~~r Avowing+iolati~m., OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form ;,320-1 (Rev. 3199) Previous e <br />~fhi~ i~ a -1-part fi~rtn. PAGE OF <br />