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PERMIITEE NAME/ADDRESS ilncludr Facilirr :Vamdl.tx'arion ij fhjjrrrnp <br />NAME <br />ADDRESS ~ .-.Je <br />~~x 6~%; <br />. H ~.O 814'_4 <br />FACILITY ~~~ ~ Z~~V (vl 1- 14~ <br />LOCATION A ~ CG 91424 <br />I AnIrG I.IGF11^. t~iTrJF MAt•3A(~FR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />pMB No. 2040-0004 <br />SR3~MIr+IE DRI~iG <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION ND, FREQUENCY <br />of SAMPLE <br /> EX LYSIS TYPE <br /> ANA <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT ~ - ~ ' '~ + L ~° ~ ~/ <br />' PERMIT - . -"r;i -r'Cii~ T P. f';~~=' <br />~ - `,• `- <br /> REQUIREMENT ~C~Ci:. .- - t7t~ 1l_ <br />~ _ <br /> SAMPLE <br />~ <br />~ <br /> MEASUREMENT t <br /> PERMIT .. RE~Ci~? i ~ - . <br /> REQUIREMENT , J uH } ' ~ ~- ~~ ~ - <br /> ~~ -( ~ /,~ <br />. ;v; MEASUREMENT _~ ~ <br />_ <br />- - PERMIT <br /> REQUIREMENT '+-:~,}!~ A~%G Y rlx <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TfTLE PRINCIPAL EXECUTIVE OFFICER I +r•rtif) under prnalq or law mat thi+dnrument and ali auachm.n~+ »err TELEPHONE DATE <br /> and under my dirrctiun ur supcrvlsiun in xcnrdarnr with a a~strm dr+ikmd <br />re <br /> p <br />p <br />to assure that qualifiad prrv~nnel proprrl~ Kather and e+aluate tlx infnrmatiua <br />~ <br /> <br />-- - - mbmined. Bird ~m m~ Inyuin ~d the yerwn nr persons who manalte Ihr +ysirm. <br />~m+ible fur ICdM•rinlt the informati~m, the information <br />th res <br />o <br />di <br />r <br />th <br />~ '~ ~ <br /> p <br />pers <br />r <br />r <br />ar <br />ux <br />ns <br />k _ <br />~ ~ ~I <br />1 _ - <br />l tc- <br />whmitted h, to the best of nn knowledge and belief. we. rrcurute. and cump SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />' <br />l I am aware that there ore signifirnnt penalties for suhmiuine false inforrnaGun. <br />OR AUTHORIZED AGENT <br />FI AREA <br />TYPED OR PRINTED including the possibilih of fine and imprisonment far knowiag.iolatloas. OF <br />CER D NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference an artacnmenrs nere/ <br />EPA Form 3320-t (Rev. 3!99) Previous edita~.=. ~-::: ~•"-~~ <br />This is a $=part form. PAGE -oF <br />