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PfRM1TTEE NAME/ADDRESSprrvireWryN.+/Loeatew(/D(Qb.wv) <br />NAME <br />ADDRESS <br />. ~SUi~ 14;i~ <br />:..ii.Uc CV ri;: <br />FACILITY , :i 1 J )r A u H 'T H t+ S',; U ti PS 1 ~i b <br />LocATTDN p ei L I 5 A L t C U tt' L_ <br />Form Approved <br />NATIONAL POLLUTANT dSCMMOF ELIMINATION SYSTEM NPDESI OMB NO. Z04(}-~1~4 <br />DISCHARGE MONITORINU REPORT /D RI <br />PERMIT NUMBER dscHMOE NtlMSfi! T ti i' <br />.. ; , <br />MONITORING PERIOD ~ I ~ F `~ <br />YEAR MO DAY YEAR MO DAY _ <br />FROM TO I ~I <br />NOTE: R~~d kt•tructlorw b~iw~ t pl~tfnp this itxm. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. FnEOUENCr <br />SAMPLE <br /> of <br /> EX ANUYSS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ <br /> MEASUREMENT <br /> <br />_ ._ PERMIT - ~ Y - - ._ . 1.: i ~ 1. • <br /> REQUIREMENT <br /> <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 nnU7 u er pease t( et err. tMt thh do~ru rnent end .11 ^IlKhmenls wen <br />TELEPHONE <br />DATE <br />pnperM order rnf din<tbn or ru per+-Mon In sccordenee .Ith • sntem desrl~ned <br />~~" ~ to emus Ihst qudlMd perwnnel Pr~~l Lather and t. ehrste the Infoemslbn <br />I --} subntllted. Eswd on my Inquiry of the perwn or perspe .ho msnsRe the trilrm, <br />l <br />l <br />or those pertaru dlrect <br />T resporo <br />bk for pthrArK the Infamallon, the InformeUon <br />wbmllted le <br />Io the Du1 of m7 knowlyd <br />e and btMef <br />true <br />s <br />v <br />t <br />d to <br />kt <br />J <br />. <br />~ <br />, <br />, <br />ee <br />n <br />e. an <br />arp <br />e_ ~ <br />1 srn ^wsn Ural then sn fl(Nfkint ptnsitJe fer submlttin~ hbe Infermstbn <br />iIONATVRE OF PRINCMAL EXECUTTVF - <br />TYPED OR PRINTED , <br />tnchdln~ tAe podDllltr or line and Irnprtsonmrnt for kno.InE .Idstlor~ OFFICER OR AUTHORIZED AQEPlT CODE NUMBER YEAR MO DAY <br />GOMMtN 1 S ANU t~r~rtnn t was yr nn r . rv~n r rvn~ fr*~nrinctr M ~ttscnmmu n~i~/ <br />_ , _ - <br />EPA Form 3320-1 (Rev 3199) Previous editions maybe used This is a 1-parr form. PAGE OF <br />