Laserfiche WebLink
PERMIITEE NAMEJADDRESSl/nrlode Fnrilin.ti'amr/Iltrarian ijlh%Jerrnrl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDESJ <br />DISCHARGE MONITORING REPORT D R <br />Form Approved. <br />OMB No. 2040-0004 <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 UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty .d taw that thi+ducumrnt and all attachmrnt+ wrrt <br />d <br />d <br />. di <br />ti <br />i <br />i <br />i <br />d TELEPHONE DATE <br /> prrparr <br />un <br />er m <br />rec <br />on or wper~ <br />s <br />on <br />n accor <br />anrr ~ ith a si+trm da+iYned <br /> to aswrr that quulifird prrscmnel prnprrlr guthrr and eealuutc thr informaG~w <br /> whmiued. Bused on m~ inyvin of thr pcrmn or pcrw~ns who mmw~r thr .} aem, <br /> ar lhau pen.m+dirn-gp responsible for >;atherin>; the informmion. thr information <br /> wbmlttcd is, to the last ~~! m. knowledke and helief. trur, accurate. and cum{detr. <br />1 am awarr that thrrr arc si>;ni(rcant penaltie+ for suhmittink false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED . <br />iorludin~ for p~nsihiliry of fine and impri<onment for knowing siulations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />yUMm~rv I J AfVU CAYLAIYA I IVrv Vr HrvT VIVLA I IVIVJ (H@/el'@I1CB all ail9Cl1I17el1(S I1efeJ <br />EPA Form 3320-1 (Rev. a~99) Previous editions may be used. <br />1~his is a =i-part form. <br />