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PERMITTEE NAMEr'ADDRESS tlruluJe Fadlin Nome/lneorinn i/'Di~errnr) <br />NAME <br />ADDRESS <br />~l-`. <br />FACILITY ` ?. •t~; <br />LOCATION i.;; ~..Y e,; ; (~; f ~ ~ ~; <br />Bt .t !-1Tt I Af2n, t~Ii faF PkAtVA£.`;=R <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMR) <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 NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />I SAMPLE <br />II` MEASUREMENT <br /> PERMIT ~ . ,> > <br /> <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 />NAMElTiTLE PRINCIPAL EXECUTIVE OFFICER i rrrufy under prnalty of law that this document mtJ all attachments wcr TELEPHONE DATE <br /> ~~~re pard under my' dind:tton or supervision in accordance wuh a system designed <br />S <br />~• <br />~ to aesurt [hnt ywlified perstmnd pmpcrly gather and evoluntc the mfornwtion _ <br />r o <br />! . . ~ <br />-~< < submitted. Based nn my inyuiry of the penun or persons who tnarutge the system. -___ <br /> the infommumt <br />crsotu dtrcctly responsible (or gathering the inlormntion <br />M those - <br />C' r , <br />p <br />submmnl is. to the best of my knowledge and betel', true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - _ e <br /> 1 am aware that thane m significant penalties for submitting (else infornwth~n. <br />l OFFICER OR AUTHORIZED AGENT <br />I AREA <br />NUMBEfl <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED ittcludmg the posstbihq of fine and unpnsonment fnr knowing vio <br />ations. CODE <br />COMMENT5 AND EXPLANATIVN VI- ArvY vIVLAI IVN~ (rrererence an aaacnmenrs Here/ <br />:: ~-1R PF2.Et:. TR ct~t~F!T -•- Srr I . ,~. 1 , PC`- ?. Ft7~t F <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. Th!~ ]~ .1 -1-haft f%~rm <br />