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PERMITTEE NAME/ADDRESS Nndudr faciGry• A'amc/Gtrmiun rJUiJfcrtnd <br />NAME _ I_,_ <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINAnON SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />MINGR <br />f SUDR MH <br />r - FIWA <br />Gp!C.M17 T FiK <br />Form Approved. <br />OMB No. 20440004 <br />~/ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br />- REQUIREMENT .,.: I ..it :;.- ~•~•:: i ~`1.:' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -~:r ~ ., ~ x 1 .~ <br /> .REQUIREMENT l3~ ~~ f2 ~ ~ ~~~ ~+L' ~• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT '- .., 4 _ _ _ _ <br /> REQUIREMENT ~ +: i T'= -'~'~~ .. . . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ -~ ,- -~- ~ ~ .. ... <br /> REQUIREMENT - <br /> SAMPLE <br />' ~ MEASUREMENT <br />" ~. 3 PERMIT . ~ .. .. _. _ . . <br />` :REQUIREMENT _ ._ -, A`:'G r r,; ~,. ,. ; <br /> SAMPLE ~ ~ •` <br /> MEASUREMENT <br /> PERMIT - .. .. - .. ~ ., _ . _ ~ , . . <br /> REQUIREMENT 1' `` `' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ._ t _. - ~,. .- - . . ,. , , •- <br /> REQUIREMENT _ ~ .. , r}f. ?. `... • . -. <br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I rrrtit> under petudt+ orbrw that thiseucumrm and au mtacbmcnt+ wen• <br />• <br />ed u <br />Jrr <br />di <br />cti <br />r <br />with <br />i <br />b <br />i <br />d <br />' <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> pn <br />pnr <br />m <br />my <br />re <br />on u <br />+u herv <br />s <br />m <br />n acc„r <br />ww <br />e <br />a a}s <br />rm <br />~ <br />gne ---- <br />- <br />-_ <br />~ In ussu re that qualified prrwnnd prnpcrl~ gather and rsaluute the in(nnrtmiun ' <br />~ <br />~ , <br />'- +uhmittrd. Ra+ed un m+ inyuin of the person ur prrwn+ who manage the system, ~ + <br /> <br />' - '" <br />or those penun+dinw•d+ r~.pm+ihle for gathering the infurmatlon, the informutlon `~ J <br />_ <br />. <br /> <br />A <br />i ~ -. <br />~ +uhmit[ed i+. In lht• best of m) kmrwledge and belief, true, aceuratr, and compMte. _ <br />~ -; .! • - <br />! <br />• <br />, ~ =• <br />~ <br />' ' ~ I am aware that them arc signifkam penrltk <br />for whmiiting fal+e infurmadon SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />~ <br />` ' <br />TYPED OR PRINTED . <br />. <br />including Ihr pnsibilit+ of fine ata! tmpriwntmem fur knowing +i~dutions. OFFICER OR AUTHORIZED AGENT AREDA NUMBER YEAR MO DAY <br />t,vmmct~ t ~ Mtrv cnrt~strr t tutu yr r•tv r rtvt_r, t tvtvo Irtrrt:rence an arracnmenrs Here/ <br />EPA Fotm 3320-t (Rev. 3591 Previous editions may be ~s?ef <br />~il?~ i~ ,1 -1-~~.T( (t~Iltl. PAGE OF <br />