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PERMITTEE NAME/ADDRESS /Im•hdr PaclliA•.1'une•Y.ororirm ijDiJjemnr) <br />NAME <br />ADDRESS. - <br />FACILITY <br />LOCATION - .4> <br />,.. ~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMEIER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved, <br />OMB No. 2040-OW4 <br />i <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ' <br />"~ - :' MEASUREMENT <br /> ti .. _ .. + <br /> PERMIT <br />'- t ': i '..J'_ REQUIREMENT <br /> SAMPLE <br />i-C - ;: ;_ - MEASUREMENT <br />t+ PERMIT ~ is ~ - r I ~ ~ ~ ~ - _. , ~ . .. <br />F~L-'~'~-' REQUIREMENT 3':iL'fy ~.'.'_= ,7L.'Y i•tI. <br /> SAMPLE <br />~ ;; `~'; ; '~ - " MEASUREMENT <br /> " # - ~ . <br />~ <br />, - ' <br />ri-: ~ ,: <br />I : ~ PERMIT - <br />_ <br />. <br />'=1= F'i-V+~N f 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/'fITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of la+s that tha dexumrnt attd all attachments were <br />arcJ und~Y my dircctiun ~x supcn isiun m accordance with a system destgnzd <br />-~r TELEPHONE DATE <br />i <br />~ cp <br />:o ussutz that qualified personnel properly gather and evaluate tM: information r_.~ <br />. <br />J / G/Y' . suhnuttcd Based nn my inyutn~ of the pcrxm nr pcr.+ons who ttutmge [he SySicrlL <br />the infnrtnaticm <br />ensiblc (ur gathering the mfortnunnn <br />or those <br />ctsonx dirccU <br />rcs _ f <br />.a•~ <br />w <br /> , <br />y <br />p <br />p <br />submitted is. w the beet of my knowledge and belief: trvr, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ ~ - - ~ <br />~ - <br />` I am aware that thcr arc significant pCnaltiec for submitting false mfnrmamm. <br />l OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />TYPED OR PRINTED ahorrt <br />inchiding the possibility of tine and imprisottmety Cnr knowing vio <br />COMMENTS AND EXPLANATION OF ANY <br />(rrererence arr aRacnmems nere~ <br />EPA Form 3320-1 (Rev.3/99)Prevlouseditionsmay be used. {1:!> 1~ ~i -1-h~tr't l~~r~;: F~'`` ~''- <br />