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PERMITTEE NAME/ADDRESSpaaMJa F«WryNrwa/LoeararlJD(Qbrerrr)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM INPOESI
<br />DISCHARGE MONITORING REPORT /O R)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />QUALITY OR CONCENTRATION
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALrsls
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ' G°r"'> ° er pena tr o kw that thb doevmenl and all Ntachmenb were
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<br />submitted k, to the Dett or mr knowkdke and betler, true, accurate, and compkte.
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<br />IONATURE OF PRINCIPAL EXECUTIVE
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<br />TMpED OR PRINTED 1 am aware that there are sl~nlllunt penatNo ror auDmlttln{ hbe Inrormaton,
<br />Indudln` the poadDllity of one and ImpAaonmenl for knowintl vldatloln j E
<br />OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />I COMMENTS AND EXPLANATION OF ANr vIVLA I Ions Inntrnncra sn ~rr~cnm~nra nerp
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<br />~ r}Tht$ is~art4 fpnp. PAGE ~OF
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions maybe used. `31•~ ~i •~ • •' W ~ - ~~'
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