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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifD~erentJ
<br />NAME r
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<br />ADDRESS ~_~;~,~ i.~yr~.Ti. i ~~ S: ~"sl`Y`i~~1I'~ ;'i.. h,
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />FACILITY I i : t rat. ~ Siti .~ ( r : ;4i r`t': MONITORING PERIOD
<br />LOCATION 1 Ir x-, YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />rv, ~, `r({; Imo: OMB No. 2040-0004
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<br />PARAMETER v
<br />QUANTITY OR LOADING v -__._...___ .........................
<br />QUALITY OR CONCENTRATION .........
<br />NO. .M...~~ ~,y ~~~
<br />FREQUENCY
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<br />SAMPLE
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<br /> SAMPLE
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<br />REQUIREMENT
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<br />MEASUREMENT /~~}
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<br /> PERMIT
<br />REQUIREMENT
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<br />MEASUREMENT
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<br /> PERMIT
<br />REQUIREMENT
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<br />MEASUREMENT
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<br /> PERMIT
<br />REQUIREMENT
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<br />REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTIVE
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<br />tttt FFICER I certify under penalty of law that this document and all attachments were
<br />prepared under my direction or supervision in accordance with a system designed ~t
<br />~ n /, T ELEPHON E DA TE
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<br />[o assure that qualified personnel properly gather and evaluate the information
<br />submitted. Based on my inquiry of the person or persons who manage the system,
<br />or those persons directly responsible for gathering the information, the information ~t~i
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<br />submitted is, to the best of my knowledge and belief, tme, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />` ~~ `~~~~
<br />TYPED OR PRINTED I am aware that there aze significant penalties for submitting false information,
<br />
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<br />COMMENTS OND EXPLANATION OF nNY vlnl
<br />including the possibility of fine and imprisonment for knowing violations.
<br />nTlnNC iaefo.a.,,.e ~u ~.r,,.-,..,e...~ w,..,.. OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ;~ ~ j ~ -; , _ ;~hj3;1S Q 4-per.€Oriri. PAGE _ OF
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