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PERMf1TEE NAME/ADDRESS ilnrfudr F'urJihr:Yomr/Lacarion iJAiJ/rrrnr+ <br />NAME <br />ADDRESS ~ - <br />_N <br />FACILITY HOi <br />LOCATION ~ ~ A <br />t n. <br />MG <br />DISCHARGE MONITORING REPORT (D R) <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 />NOTE: Read Instructions before completing this form. <br />~~ I <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY <br />of SAMPLE <br /> EX NALYSIS TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT R _ .r r <br /> REQUIREMENT , , - - - <br /> SAMPLE ' <br /> MEASUREMENT <br /> PERMIT ... ~~>ti , ~ .. dt~>;r, x-: ,<c _,. , z% <br /> REQUIREMENT - - ~ ~ r <br /> SAMPLE ` <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT I !~~ i r~, . ' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/'fITLE PRINCIPAL EXECUTIVE OFFICER I remit) under prnalq allae that mes ducament and oll attachmrntx score TELEPHONE DATE <br /> prepared under m~ direction or supeni+ion in :u rnrdance .~ith a s~~stem designrd - <br /> to a'sure that qualified perxmm•I prnprrlr gather and es uluutr the Infurntatllm ~ - ~ ~ - <br />_ __ <br />_ .uhmitnd. Ra+rd on my inyuin ~d tl,r prrvm or perWm+ whu nuaagr the +~stem. - ~1 <br />_ ur Ih,ne perWms direcU) n. pemsiblr (a galhrring the information. the informaton ~ f -- <br />~ <br />` <br /> ~ ~ <br /> <br />~ <br />~ <br />j <br />` <br />i suhmitted is. to thr hest of m. km,aiedgr and brlief, tree, accurate and aanpkte. <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />~._ <br />. <br />. <br />~, l um aware that them are +ignifaant pennlties for +uhmiuing false informatiom. <br />AGENT <br />TH <br />RI AREA <br /> risonment fur knowing violmion~ <br />nd im <br />l <br />di <br />+ <br />ihili <br />f f <br />i <br />th OFFICER OR AU <br />ZED <br />O NUMBER YEAR MQ DAY <br />TYPED OR PRINTED p <br />e pu <br />+ <br />ry o <br />ine a <br />nc <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 IRev. 3.~93I Prewc~s addwns may be used. <br />NATIONAL POLLUTANT f~SCHAgGE ELIMINATION SYSTEM (NPDES) <br />5F~ z. <br />5T M©N <br />ii:39i: Thi; is a 4-Part fi <br />PAGE OF <br />