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Fo,;~, Appro red <br />PERMITTEE NAMEJADDRE55QnabJrf•rWryNww/F.or•rlow (/P~Qlr.wv) NATIONAL POLLUTANT a3CHAR0E ELIMINATION SYSTEM NPDESI OME No 2040-0004 <br />NAME . I~' DISCHARGE MONITORING3 REPORT /OMR/ <br />ADDRESS ~' ~` <br />t <br />..I I l ` ~ ~ ... <br />PERMIT NUMBER ascHAnoE NuMSEA <br />=RS~T C~ <br />FApLITY 'OF.N G'RK ~ ~.LK CRS, MII I MONITORING PERIOD <br />LOCATION '-RSE r <br />~ <br />' YEAR MO DAY YEAR MO DAY <br /> ' FROM TO <br />9E5 T . COl7PER, EXFC V F'. <br />8UR f' RUhiL~~'f= T'C1 !V ~ K i~Uf+ti S R I V` <br />~: <br />NOTE: Read If>.trucNotr b~lw~ compbtinp thb form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREC <br />U~NCr SAMPLE <br /> EX C <br /> AHAtrsfs TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ~ ' <br /> REQUIREMENY <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ~ `- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ,... ~ .. ,- ,.... - . _ <br /> REQUIREMENT i ' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ .. _ L F. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />~ ~} PERMIT ., ,-. x~ _ - <br /> REQUIREMENT - ;'., <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMEN'C <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERM17 ~ - _ -. <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER t nntt7 v . pen• 17 a 1•w u•t tAb dorumeM •nd •u .i(•<nmenu .ers TELEPHONE DATE <br />prsp•nd order tn7 dlre<tlon or wperMfon In eccord•nce with • s7ltem declined <br />to more ihN qu•Mfkd personnel progeA7 ~•ther •nd er•lu•le the Infnrwytbn <br />lobmltted. ~eaed on m7 Inqulr7 of the person or ptrsom whp m•n•~e the lyltem, <br />or thole penots dlre[t17 raportdbk for ~•Ihennt the Inform•tlaw, the tnferrn•llon <br />wbrrdtted tt, W tht bet of m7 LnowW re •nd Detlrf, troe, •c<unte. •nd <ompk(e. <br />1 •m •w•re U•t (titre •rslf <br />nlnom <br />en•Itle! ror r.bMnint rdx inrormeunn <br />610NATifRE OF PAINC1iAL EXECIITtVE <br /> r <br />p <br />, A A <br />TYPED ~ PRINTED IncludlMthepodblllt7ornne•ndlmprtnwmentforkno.lnf•folal)-,rn <br />_ OffICfR OR AUTHORIZED AGENT <br />_ NuME1fR <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /R~l~r~nc• s/1 •tt~cAm~nt~ h~r~l <br />Ttl~s r<s a 4- art form. PAGE OF <br />FDA Form 3320-1 (Rev. 3rd) previous editions may be used. P <br />