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PERMITTEE NAMElADJRESS tLu.•ludc Facifin• ,Vurr>zR.xmina iJDiJjrrenrl <br />NAME <br />i ~:.. ~ : i~'s.. <br />ADDRESS <br />,n ~` <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 />form Approved. <br />OMB No. 2440-0004 <br />r2 ~i_H,iY 1 <br />,`~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE • <br />~/ I ;. ' '+.. MEASUREMENT <br /> <br />'~ ~ <br />PERMIT - <br />, • -::r <br />,.. •.. , - <br />.. -. .. ,~ <br />I" .. REQUIREMENT (.iC'i r;_, <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 />NAME,li'1TLE PRINCIPAL EXECUTIVE OFFICER 1 ~'~r<i~}' under penalty of Inw tlwt this d~KUment and all uttachmenta µert TELEPHONE DATE <br /> prepared under m~~ direciu+n or suprn~isiun m accordance with a sp.tem desigrcd <br />~• <br />` to as~urr that qualified penonncl properly gather anJ evalw~te the in(ormntiun <br />~ <br />.~ ~r.~1 <br />- satxni«cd. Bmcd on my tnyuity of the peon or pcnon+ who rtwnage the sys[em, -- ~~ <br />- - -- <br /> tfie information <br />or thocc petsoac directly reslx+nihle for gathenng the information --- ~= ~ '= - - <br />C r ~ , <br />submitad is, to the best of my knotalydge and tkhef, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - .. - [ - <br /> I am aware Chit there are .igmificnni pcnnltic~ Inr wbnutting (ulxe mfornntimn, <br />i OFFICER OR AUTHORIZED AGENT A <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED olamrm <br />including the po~,ihilirv ni lint and inipricnnment for knowing v CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />~R °RfC'IP F=;JcPI?° - ^r=~ ? P 1, PG 3 FOR <br />EPA Form 3320-1 (Rev. 3x'99) Previous editions may be used. - '-~ X175 ~3~$ 4=pacf form. <br />- OF <br />