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Form Approved. <br />PERMITTEE NAME/ADDRESS D„i„e; f anA:1 \eo;, l„~rtn~,; rl N;g.rnu; NATIONAL POLLUTANT GI~Gt,ARGE eura;rJAt;oN svsTer.• ffNPDESf OMB No. 2040.0004 <br />NAME _ ~ DISCHARGE MONITORING REPORT (Dtl?RJ . <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER ~ I tti q! MN <br />MONITORING PERIOD ~ <br />FACILITY '~ / <br />_ YEAR MO DAY YEAR MO DAY -- <br />LOCATION FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING OUAUTY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIS SAMPLE <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />SAMPLE <br />MEASUREMENT ,, <br /> .~. ~ r - .. ,-~ <br /> PERMIT <br />REQUIREMENT ... ii? { <br />~ i'~`-' i i4f+}: <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REOUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REOUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMR <br />REQUIREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I rertiry under penalty of la» that this document and all nttachment+ »rre <br />prepared under my dir+rdon nr supeni+ioo in accordance »ith a sy+tem dr+iRr.rd <br />! .^` _ _ TELEPHONE DATE <br /> <br />- - - -- -- ~ - <br />- to a.+vrr that yualifiad p•ra,arncl properly µlher and ea aluatr the information <br />+uhmitted. fSavd uo ms inyuin of the prraro or perums »ha munu)+r Ntr sy+t<m. <br />n+1Mr for ppthrrimt the [ntormntinn. the Information <br />di <br />tl <br />b <br />, ~ , ' <br />~ <br />~- ~ <br /> <br />.. <br /> <br />~ <br /> <br />~ ; <br /> <br />- <br />: 1 <br />.. ~- <br />1 - <br />+-' y <br />osr rwn+ <br />rec <br />or t <br />kno»iedgc and belief. true. as<~untr. and ttanplrle. <br />+ubmiltrd i+, to the best of m~ <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~~ <br />- _ ~ ~ - ~ -L~ <br />~ <br />~~. <br />~- •{ `~' ~ --~ i am aware that there me siYnirkant penaltie+ for wbmittink falx information. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTf:D i~ludinR the p,xsihilitr or~ne and impri•onmrm roe krro»inK+i,dations. D <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments ~erel ~ f -~ ~ppL I FD 1=!3R 1 nYR/24NR I}RF_C IP EVENT - SEE I . A. 2, ' <br />PAGE OF <br />'T'1 '. ;~ 1--t ire t~vn~. <br />EPA Form 3320-1 R.-: Via, P•-.... <br />