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PERMITTEE NAME/ADDRESS(ln~M6F.eWryN~r~Leea~en~/DlQinwv) <br />NAME <br />r <br />ADDRESS <br />dU~ I4.iU <br />..;aL`i. CL, b1. ~ 1E <br />FACIII'El' ~ j p~ :~ u it 1 h t, S U iJ T h hI I h :: ;; <br />LocATION P A L i :, :+ U~ L t: b 15 [ t <br />. ': rl u 1 L' T !' c. v r <br />Form Approved. <br />NATIONAL NOIILfTANT OISCNAROE ELIMINATION SYSTEM NPDESI OMB No. 20x0-ooo4 <br />DISCHARGE MONITORING REPORT ID Rl <br />~. ~tbtt uwl <br />PERMIT NUMBER DISCHMOE NUMOEIt F j h J L ~ <br />"~" CCAL CfitEi4 <br />MONITORING PERIOD ' <br />YEAR MO DAY YEAR MO DAY _ <br />FROM TO _ <br />NOTE: R~rad Ir>•tructlons 6.1or• cmm~l.tino thlt itxm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. uFNCr <br />FaEC SAMPLE <br /> ~ <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANAtrsts TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> <br />. PERMIT <br />REQUIREMENT <br />• ~ <br />` • ' <br /> M• H . ; ~. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - / ... ., i t. / : t, r <br /> REQUIREMENT <br />- <br />~. <br />-- ~ <br />SAMPLE <br /> MEASUREMENT <br />y ~ PERMIT --uz^ti6 ."~r~•~rct .. i:.tG~I ~~.:/ :, ;;: <br /> REQUIREMENT <br />' <br />' <br /> ~` <br /> SAMPLE <br />' <br /> MEASUREMENT <br />,..~ , <br />1 PERMIT _ :; >'~r,~:r .. <br />` "C <br />/ v ~' ~ <br />~ ^ / <br />• ~• r <br /> REQUIREMENT ~ ' ; <br /> _ r ,. , , <br /> SAMPLE <br /> MEASUREMENT <br />- - PERMIT ~ s •; :,y.i ~. L A'j ;. <br /> REQUIREMENT <br /> ~ ~, <br /> SAMPLE <br />~~ , <br />.: Z:sGN~t.~~tLhl !'i MEASUREMENT <br />.~ PERMIT , ' ~ . ; ~. i!i: ~ ~ ., .. '= - ,... , .; ", , :. t <br />' <br /> REOUIREMENT <br />.. t ~ <br /> <br />. .. SAMPLE <br />, <br /> MEASUREMENT <br /> PERMIT •, r. .i .. : V : . ~ i `t w i ..:. <br />, <br /> REQUIREMENT . . <br /> ~ <br />, <br />" <br />~" <br />. <br />n <br />- <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFlCER "'"""` .rd .° <br />t <br />cnment..e <br />' "^"~ " " pe""r a Lw tn" `"n d <br />r <br />d <br />l TELEPHONE DATE <br /> p <br />ep.re <br />undrr m~ dlrect <br />on or fupeM.low In .crord.nre wllh . fralem defl~ned <br /> to usurt Ih.l qu.Mfled perwnnel pnoyrrt~ dal ber .nd rr.lu.le Ibe In/erm.lion <br />b <br />lu <br />d <br />B <br />I <br /> su <br />m <br />red on m~ <br />e <br />. <br />"qu1rT of Ut person or penoro wM rtrn.~e the f~ttem, <br />e <br />tb <br />dl <br />u <br /> r <br />ose penoro <br />rec <br />T reapordbk ror ptAerlrK the Infornull°w, the inlomrtfon - <br /> wbmitted b. b the bnt °( m~ knowted~e •rd beNrf, Irw, twcvnte, .nd complete. , <br /> I •m •w.rt lba tbert .re d(Nfk.nt pmNNn ror .ubmittln~ t.be inforrrul{on. 61ONATLIRE OF -RINCf-AL EXE CIlTIVE ' <br />TYPED OR PRINTED tncludl^L Ibe po>e16141y or floe .nd Imprisonment for knowing .Id.uonn, OFFICER OR AUTHORIZED AOEKT COOS NUMBER YEAR MO DAY <br />GUMMCIV I J Arvu t:~ra.nnn t rvr. yr r,.. ~ . ~.,..,. ~ wrw fn to trrmc• rr ~ntrcnmten r~ n~itri <br />EPA Form 3320-1 (Rev. 399) Previous editions maybe used <br />~~ <br />a ~l-pan form <br />~i <br />