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PERMITTEE NAME/ADDRESS Qnvid, FaeWryNrerlxaelow 1/DIQG.wv) <br />NAME <br />r <br />ADDRESS _ 1 ., . .. ~ v / <br />bOe :~t,3U <br /><SADL• ~.C bi5tt <br />FACILITY <br />LOCATION . 5 I :1c; .l .i h; is o S U ~ T t; :! I t+ c :, <br />i%ALZSdCE CG ~i52t, <br />crtu r ^ r nr c c ~ n <br />Form Appro~.ed <br />NATIONAL VOllllTANT OiSCMAAOE ELIMINATION SYSTEM (NPDESI OMB NO. 2040-0004 <br />DISCHARGE MONITORING REPORT (OMRI <br />PERMIT NUMBER DISCHAAOE Nt1MEE1! ~ , L ~ ~ <br />- - - t7r SA <br />MONITORING PERIOD - • L <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: R~~d Irt~trvctior>. 6~1or• cmm~l~tlna thl~ (Ixrrt. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. EN~r <br />ITtE°o SAMPLE <br /> F <br /> EX µ,+,Ly~s TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ( <br /> MEASUREMENT <br /> <br />J ~ PERMIT <br />REQUIREMENT h k C : " Y - ~. L '2 , <br />" ~ " ' <br /> T ~, _ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REOUIREMENT <br />NAME/'fiTiE PRINCiPAI EXECUTIVE OFFICER ' """' " " p`""~ ° ''" ehu uh °°"'"""' .nd .n al.rhmenU "ere <br />TELEPHONE <br />DAT <br /> R .red under in dlrrrl{On or w <br />D p 7 per`ldon In accordann "Ith . e7elem destined E <br />I <br />'- - !o assure lhal quaNM1ed personnel properly [.Iher .nd .. aluale lht Infornullon <br />a°bmllled. bred orr m~ Inquiry or the person a penoro "ho manage the syfleln <br /> <br />( , <br />or IAwe Denom dfrecllr rrs <br />o.~bM for <br />a1hMn <br />the I <br />r <br />li <br />I <br /> p <br />~ <br />~ <br />n <br />errru <br />on, the <br />nformallon , , <br /> submllled h, to the bell of m. kno"ted~e and benef, Iroe, atcvnle, ^nd complete. - - <br />~ <br />~ I <br /> l .~ ^".re ual acre are d~rdfinnt pm.lHes ror abmllnnt rape lnrorsrrtlon. iIONATURE OF -RINCtrAI EXECUTIVE - ' <br />~ ' <br />TYPED OR PRINTED lnrtudlrrtlhe podbiny ornnr and lmpAsonment for trq"lrK .tolattona OFFICER OR AUTHORIZED AGENT COOS NUMBER YEAR MO DAY <br />V Vrnr.ILr.r~ r~r.V ~~• rr~.~~..~.. ~. _... __~....~..~ ,. ~. ~. ~....~ ~. ~..~.....,.~r..r •r"."r <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. TIUS IS 8 4-Pell TOTitI. PAGE OF <br />