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PERMITTEE NAME,'ADDRESS tlnclark/~acilin•:Vamc~YwxarinniJDiBrrrn~~ <br />NAME ; "~i <br />ADDRESS ' <br />1 D b .°s <br />._ ;:~ ,~ <br />FACILITY <br />LOCATION; , :.O E31 <br />. r.c~r~. ~~ r r.t= nfnn~n,: <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. 2040.0004 <br />NOTE: Read Instructions before Completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np, <br /> <br />~ FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />r 1 ' =,i SAMPLE <br />MEASUREMENT ,~ j <br />%r` "! <br />- ~ - PERMIT <br />r 1= ~ . '_ . REQUIREMENT " <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/'fITLE PRINCIPAL EXECUTIVE OFFICER 1 ccrhh under pcnaln• of law thta thts diwumcnt and all annchntenis were <br />dtrn~tion or sup<•n•isum in aaordnnce with n sy~tcm designed <br />r <br />ar <br />d <br />nder m TELEPHONE DATE <br />~ <br />.: ! [.~ N ~ ~ ~ ep <br />t <br />u <br />y <br />w .usute that qualified penonncl propcrly~ gather and esaluate the mfOrmatipn <br />submined- Baud on my inyutry of the person or persons who manage the system. <br />- "' <br />~ <br />~ ar tlxtse pcn.ms ducctly respunsiblc for gathenne the informaticm. the iufrwmauon <br />submuted is, to the best of my lniwledge and bcGet; tntr, accurate, and caimpleta SIGNATURE OF PRINCIPAL EXECUTIVE ,! <br />- 1 am aware tlwt them arc significant prnnltia4 for ,zibmnnng falx infomwtion. THORIZED AGENT AREA <br />OR A <br />TYPED OR PRINTED including the pexsibility nl fine and unpriummeni for knew mg sioln[ionc OFFICER <br />U <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANAI IVN Vr ANT vlV~il wrva Ixererence an eaucrunt:rns nvre~ <br />i-iR RAC I P . EUEN~' - ~E~ <br />i _ _. SF~t~1PL I I~if I NSTR':JC1" I D!~ <br />EPA Form 3320.1 (Rev. 3199) Previous edftions may tye used. ~- ~ hiti l~ .~ •~-{yan f ~ n"m. <br />