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Fotm Approved. <br />PERMITTEE NAMEJADDRESS Include Faai(ge ~ume:~Isnn n~o: rj htjjrrrnt NATIONAL POLLUTANT DISCHARGE EUMItJATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2D40-0004 <br />NAME , <br /> IAN <br />ADDRESS PERMIT NUMBER DISCHARGE NUMBER - F' T I~•I,AL <br /> <br /> MONITORING PERIOD <br />FAaLm ;;~ ;, ~ :_ • : , , ; ; ; ; , - YEAR MO DAY YEAR MO DAY <br />LOCATION • L ~ FROM TO <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIS SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> <br /> MEASUREMENT _.,, <br /> PERMIT <br />REQUIREMENT '~ ~r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />SAPJIPLE <br /> MEASUREMENT <br />._ <br />, <br /> <br />• ~ PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMFJTITLE PRINCIPAL EXECUTIVE OFFICER t ~crti[y under penalq nnaw that u~i+du<umem end vll attr~•hm~m.. ~~r~ <br />prepared under ms direction or ropers icon in aceordanar with a ss 9cm deigned <br />_ TELEPHONE DATE <br /> <br /> <br />_ <br />- ~ o~ acmrc that yualilkd personnel properly gatMr and r.ahwtc thr inkrtmation <br />;uhmiurd. Maned .m m. inquire of the perwm or petvms •s ho manage the system. <br />the informrtian <br />the inG.rmation <br />i <br />th <br />.. - <br />~ - - . <br />er <br />ng <br />nr thine perums dirrctly respnnsiblc fur ga <br />w thr be.t of m> kmiwkdge and belieL lnx. occurnte. and cmnpkte. <br />iu <br />d b <br />b <br />RE OF PRINCIPAL EXECl1TIVE <br />N _ , <br />_ m <br />e <br />, <br />eu <br />1 am aware that there are signtricartt penalties for suhmitting (else hJormathw. SIG <br />ATU <br />OFFICER OR AUTHORIZED AGENT AREDA NUMBER YEAR MQ DAY <br />TYPED OR PRINTED including Ihr possibility ar fine and imprisonment for ~m~w leg sinlnti<ms. <br />t h e) <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachmen s er <br />'ri ,~- .. . . ~ .~~ tn~r,~ PAGE OF <br />EPA Ftxm 3320.1 (Rev. 399 P~?: _.....,~~,. -., _ _ <br />