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PERMITTEE NAME/ADDRESS ilnrfurlr FariGtr :1 anu %hn urr•m : r t%; ~I, nn! <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION 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 />Fnrm Approved. <br />OMB No 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREl1UENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ % <br />; <br /> ~ _ ,, , <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 /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I crrtif} under Ix•nnln ul ~.r++ mnl ull+d,w'wnrm and :ru auachmrm+ erne - <br />~• TELEPHONE DATE <br /> prelrured undrr nr. dirrJ Um ur wlw~r+i+iun in as urdanar wSth a +)+Iem de+genaf l <br />~~„- <br />_ + _ lu x+vrrr Ihnl yuwbfild fw~r+nnncl pnq.erh yalhrr wrd r+aluxlr the infornr:diem _ <br />.~.a -__ , <br />H--~ <br /> +ubmillr•d. Rn+rd .m m~ Bufuin of the Ixanrwr or pcnun+ whu munrkc thr .++Irm. / <br />~- <br />~ `--~ <br /> <br />nr Ib,:x prl~.al+ durcW nspm+ihlc fur ywlhrnnl; IAe inbn'nlnliau. thr in(urmntiun ~' <br />--- <br />__ <br />-- , <br /> Io Ihr Ire9 of nn Ara,.r lyd>;c and belief <br />true <br />nn'uralc <br />:md complrte <br />+uhmilt~d n ~f r <br />_ . <br />. <br />. <br />. <br />, SIGNATURE OF PRINCIPAL EXECUTIVE <br />- I am •wan Ihal Ilkrr nrr+i~nlfirnN fw•n:dlir+ fnr whmillrnK fnl~r infonrwtirm, TH <br />RIZE <br />AGENT <br />OFFI <br />ER O <br />A AREA <br />TYPED OR PRINTED inelwdm;; Ihr p..++ibllit...f fmr :rnd hnpri.onmrm brr Am,nina +i,dation+. C <br />R <br />U <br />O <br />D ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 !Rev 3~99i Previous ediUOns may be used <br />