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PERMITTEE NAME/ADDRESS (/ncbr6FerWrjNrt•/Ler«rar Uoft1F•^r) NATIONAL POILVTANT aSCNMOE ELIMINAnON SYSTEM //NPDES/
<br />NAME DISCHARGE MONITORING REPORT IOMRI
<br />ADDRESS ~
<br />j;~}( PERMIT NUMBER ascHMOENt1MeEN
<br />~iV I A - MONITORING PERIOD
<br />FAC1lfTY , T ~ N~ , .,,~ YEAR MO DAY YEAR MO DAY
<br />LOCATION :•:Ia ~;/ ~] 1 ~' : -:, FROM TO
<br />~'.IAM A. DEAR ..1R- t f'IINE I`1Gi
<br />Form Approved.
<br />OMB No 2040-0004
<br />F - FIRAL
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<br />NOTE: R~~d Ir>.tructltxr b~fw~ compbtfny thb form.
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<br />NAMElTTTLE PRINCIPAL EXECUTIVE OFFICER ' cen~q . • pen, ry o •. thn IhM dorumen( and ,n •uachmrnn .ere
<br />
<br />prepared under ink dlrectfon a fuPervfflon In ,ccord,nre with a snlerrr dd~ned
<br />TELEPHONE
<br />DATE
<br /> to enure th,l au,llrled persannN ProPtA7 ~a(her and er Yu,(e IM Information
<br /> tabmtlttd. Bred on m~ Inqulrr or the person a persons .ho manate lM f7stem,
<br /> or Iho= persam d(rectl~ rnpemibk ror /,IheArK iht Inrorrrullow, the Inrorma(len
<br />. submitted 1s. b the bee/ or rr7 LnewkdEe and beeer, tyre, ,ec(rnle. and compote. - -
<br /> 1 am ^w,re M,1 there are sl~nl ee,nt penalties ror wrbml(tlnj b6e Inrornutbn, 610NATi/RE OF -AINCfrAI E7(ECtlTIVE :.
<br />TYPED OR PRINTED Incfirdln= the paWbltlry Dr ~ne,nd Irnprhonment for-nor(at ~•~• OFFICER OR AUT?40RIZE0 AGENT CODE NUMBER YEAR MO DAY
<br />GOMMtN I S ANU CJIr'lAl'IA t tun yr nn r vtv~n t tuna Inererence M IrrICI1/flMr! Here/
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<br />t PAGE OF
<br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used TI11S-15 8 4-~8R fOflTl.
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