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FERMITTEE NAME/ADDRE55 pnerft f~rwryM../Lerrlan I/D(Qfrrwu) NATIONAL POLLUTANT dSCHAROE ELIMINATION 51'STEM_ fNPOESI <br />NAME DISCHARGE MONITORING REPORT (O RI <br />ADDRESS ' <br />BOX ~ _ PERMIT NUMBER dscNAftOENUMeEn <br />:RSET <br />FACILITY ~ORt~I Cl-2f~..: t.._i•• is rti i~ ('I .i i .: MONITORING PERIOD <br />_i~..t1=T YEAR MO DA YEAR MO DAY <br />LOCATION ` { ' FROM TO <br />•'E~ T. COOPER. EXEC V <br />Form Approved <br />OMB ~ Jo 2040-0004 <br />ENi <br />+:~ ~_ <br />NOTE: R~~d k»tructiarx b~la~ compbti~y thl~ form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, fAEOVENCr <br />or: SAMPLE <br /> EX TYPE <br /> ANALrsfs <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. . - .. >-t- _, <br /> REOUIREMENT ;I'~ ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - .: - ~-~,~.' <br /> REQUIREMENT '~~ <br /> SAMPLE <br /> MEASUREMENT <br />' PERMIT ._, .. ~• 1 <br />`'} '--- <br /> REQUIREMENT L?~tIl_`I' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ., la.. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F .r <br /> REOUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -~ <br /> REQUIREMENT '~ MX` <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT • ~r ._, . <br />REQUIREMENT .:~~ "'~i~' <br />PRINCIPAL EXECUTNE OFFlCER t `Y"'t~ ~ r pen• y o le. inu Uy eoa~mrM end ell •tl~[hmenb were TELEPHONE DATE <br />prepend under m~ dlrerlbn or fupen6lan In Keordenee wllh ~ i)ftem dgt~rttd <br />NAMElTiTLE <br />to eaun Ihet queNfled personnel properly ether end rr Juete IM Inforenelbn <br />eubmltted. 6rM on m~ inqulr~ o! the perem or penortt who ttwu~e the rrftem, <br />a those penom dl nctl~ mpordbk for ptherlrtE the Inforrtullow, the In/errnelbn <br />wbmltted bt. to the beet of m! knewtedEt end bevel. trtle. rtrevnfe, end complNt. <br />eIONATURE OF -RINC1-Al EXECUTIVE <br /> I ~T rawere uet then sn dENfkint pentildef for weberrlttln~ hbr Infornotlon. Y <br />TYPED OR PRINTED Inr1idliK the poedDlUt! or nne end Imprlfanment for Mnowlnt rldstbre~ OFFICER 011 AUTHORIZED AGENT CODE NUMBER YEAR MO OA <br />COMMENTS AND EXPLANATION Of ANY VIOLATIONS IR~f~r~nc• sH •ttachm~nts htrr~l <br />:t F .._.~~ ~r~~C; 1.+•~1 =f3! '11-i} ."167 --? ~I? ^!I L.;[t C)!:, ^'i`Ti~ *-'t.!FI~T; <br />FPA Forth 3320-1 (Rev 3/99) Previous editions may be ured. TINS -S 8 4-PaR COnTI. PAGE Of <br />