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PERMITTEE NAME(ADDRESS Nnrludc Facilin~ Nama'L.xrarron ijDi,Qenmt! <br />NAME , <br />ADDRESS - ~ ~ p <br />S. <br />sL <br />FACILITY <br />LOCATION -. <br />NATIONAL POLWTANT DISCHARGE ELIMINATION SYSTEM (NPDE$) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />1 <br />Form Approved. <br />OMB No. 204U-0004 <br />MINDR <br />~ SLIDR DW <br />~ - g•iroaL_ t~6LAiti <br />55-~ 9LC)T STOfZr1G~ TO !~>rD WRSti , <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NO. FREDUENCY <br />Of SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />-: • -r .. SAMPLE <br />:=F ~ ::- MEASUREMENT <br /> <br />PERMIT <br />, .: -, • <br />_ •, r::~r <br />`: T REDUIREMENT ' `.` <br />t. SAMPLE ~ .. .. t <br />;- : ". MEASUREMENT <br /> PERMIT <br />r ' ~ (• - ~ ; t , _ . r•, t <br />1^r L._;J' = 'v:= ~ REQUIREMENT r•,; µ, .,J <br />` ' ~ SAMPLE <br />PCC".': - ~ MEASUREMENT <br />~; c - PERMIT ".. ~ r r. r ` : r. __ ~ t <br />c c cL!J,.; i REQUIREMENT - :3t:ir, ' ... l i. <br />r SAMPLE <br />s `; .' __ << ~ ~~ : - ~ MEASUREMENT <br /> P>_RMIT <br />F . _ _ REQUIREMENT <br />1 SAMPLE <br />l-`~ ~ _' _ - - ' _ MEASUREMENT <br /> : ~ .y. <br />t <br />- t - . <br />i PERMIT . .. <br />f _ ~ <br />. .r <br />; ~ _ <br />_r ~.-1 ',. .' .-.. ~ .. .~ REQUIREMENT =;C`t: ~~~ ~?'' `i i'/ ~ I. •. ~~~ _, <br /> SAMPLE <br />;' f~; ' ~_. MEASUREMENT <br />_ .. PERMIT ' <br />r= F ~~ - REQUIREMENT .., ,, <br /> SAMPLE ~ •~ <br />T[?TA~ ~ MEASUREMENT <br />' PERMIT <br /> REQUIREMENT ~ ~=' <br />NAME~TITLE PRINCIPAL EXECUTIVE OFFICER ~ ~ rntfy under Pettalty of law that this Document and all attachments were TELEPHONE DATE <br /> I+rrpareJ under my dinsunn or ~ltperviston in accordance w~ittt a system Jcsiurw-J - <br />~ ~ ~ - <br />7~ <br />f ~ t.~ asstat: that yualificd personnel Properly gather and evaluate the infomnation ~. ~" <br />-__~-__ ,_ _ <br />~ <br />` <br />~` <br />' subnuttcJ. Based on my tnyuiry oC the petxm or person. who manage the system. <br />the tnfortneuon <br />or thcsc persons dinxtfy nsponsrb!e for guthenng the tnfontwtion ~ <br />~ ~ <br />_ . <br />r <br />l <br />t <br />l <br />d <br />J h <br />E w <br />• <br />t <br />d <br />b <br />f <br />L <br />h y~ <br />~'` ' <br />, ~ ~ ~ <br />~` ` <br />T' <br />`- ~ I ( ~ <br />/ a <br />c. <br />est o <br />now <br />e <br />c, an <br />ura <br />c, an <br />mp <br />c <br />submitted ts. w the <br />my <br />c <br />gc an <br />e SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />' <br /> 1 am aware that then arc stEmtficnnt pertahiec for submming false information. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including thr p.~sit+ihty of tint anJ unpnsonment (ur knowing violuticros. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. I hl s is a -1-~~ar( 1 n; m. <br />