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PERM1TT12E NAME/ADDRESS Unctudc Facility .\amdLacatinn iJlHJfnrntl <br />N~SME _.- ~_ _ .. <br />ADDRESS - '' i- <br />GUUIyTY RQAL~ 1G© <br />FACILITY C~fii_ P1 i i~I` <br />LOCATION ~~ ~~~ ! ' ~ ~ <br />iVT 's~F i c~;~E:IPi, Pr,E~IDI`I`Jl <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. 204Q-0004, <br />I"f11,... <br />F - 'r ~ t~J:-~i_ t-Pt <br />` ~~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITE MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • . ,- ~ ,T : r: t .. _ - ~._ - .. <br /> REQUIREMENT - .. ';:; t~ !=,'i ~.; 'Jr=, i ;- '' <br /> SAMPLE -.. .. <br /> MEASUREMENT <br /> PERMIT I . ,. - . _ ... ... - - -° - '- <br /> REQUIREMENT (-! <br /> SAMPLE <br /> <br /> MEASUREMENT ,/ <br /> PERMIT <br />~ <br /> REQUIREMENT l. <br /> SAMPLE <br /> MEASUREMENT i I ~ ( <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />r <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEJfITLE PRINCIPAL EXECUTIVE OFFICER I rertifi under pr,wlH or lax that thi. d~sutncnl and all atWrhmcnln xrrr <br />rr <br />urrd under m <br />direction or a <br />enisinn in anrontaner with <br />r <br />Hrm d <br />si <br />nrd TELEPHONE DATE <br />~'. ~,'/ G/ ~~ p <br />~ <br />~ <br />p <br />,p <br />u <br />e <br />k <br />to aswrr That yuulffisd personnel pnq,rrh Kather atxl evalualr Ihr information -- _ <br />'-~- - ~ <br />i submitted. Rasrd un ms inyuin of [hr person nr prnuRS xha manage Ihr {Y\lem, -- , _ _ <br />- <br /> or thnsr Ix•rvom din•ctls rrsp~msihlr Gir gathrring Ihr information. the inrorowtion ~ y' <br /> .uhmittcd ir- lu the Ixst of m~ km~x lcdgr and hrlier. tner, wcurate, and almpMlr. -~ ~ =~ <br />~' ~ ~ ~ <br />- ; ~~ <br />3 ~ <br />~~ y <br /> 1 am ax an that Ihen• ore si <br />nifa <br />x'nultirs fur submittin <br />rake in(orm <br />liem <br />nl SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />- <br />~~ • <br />~- - - <br />TYPED OR PRINTED g <br />g <br />. <br />:o <br />I <br />a <br />inaludingthe pus.ibiliry of finr and impri.onmem fur knowing siulutinns, OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />?s4 -Faf <br />EPA Form~3320-1 (Rev. 3/99) Previous ediiwns may be used. This l9 8 4-~~ff` fOfril. PAGE OF <br />