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PERMITTEE NAME/ADDRESS dnrludc FacJin•,Vwn~• l.~xarinn (fDijjrrrn(I <br />NAME <br />ADDRESS <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. 2040.0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LARDING QUALITY OR CONCENTRATION Np. FREQUENCY <br />OF SAMPLE <br /> ~ TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~.' I MEASUREMENT <br />''~ PERMIT <br /> I'tt.;i•d'Fi <br />~ F : REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attu bments wem <br />dincuoo or supervtstun m ;tccordantt a~tth a system designed <br />xc <br />arcd under m TELEPHONE DATE <br />r y <br />; <br />p <br />t~~ acstue that yualificd prnonnel properly gather end evalturte the infomtuion <br />~!L f' (! .. - - submittctL Based on my inquiry of the person ur pcncros who manage the system. --'" _ - <br />4~ <br /> the information <br />unsible tix gathering the infarmattcxt <br />enor~s directly rcs <br />or those - <br />f- t p <br />. <br />p <br />suhmiued is, to the best of my knowledge and beGcl. we, accurate and complete SIGNATURE OF PRINCIPAL EXECUTIVE ~ -- -- <br /> 1 am aware tlmt there arc significant penalties for submitting false mfonnan°p' OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the posa6ility u(fine and impnsonmem for knowing violnnon. CODE <br />COMMENTS AND EXPLANATItJN OF ANY vlvLAnurva Irreverence an anacnmems rrrre~ <br />•~R t'RECIP. ~VE4~i'C - SE <br />SAMr t_2NG if~fSTR.tJCTI~N <br />!). _ ., - <br />Ei~1 Form 3320-1 (Rev. 3/99) Previous editioru may be used. <br />i. FAR REflUiREMENTS <br />PAGE OF <br />