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PERMITTEE NAMEJADDRESS ilnrlutle Frrcilin• Nmne•lnctnti~n ijDi[Ienmr) <br />NAME _ <br />ADDRESS-+--':=r:l':-_' _~JI". <br />FACILITY ;: _;r. ~lft ~( <br />LOCATIONS A!.1 ~; r` 'y ~, _, ~I <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDE$) <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 />DW) <br />I FVAL <br />a ..=.r-n ; anlvn <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION Np, pRE~UENCY <br />OF SAMPLE <br /> ~ TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />~' ,.E •," . .. SAMPLE . <br />f? r' ;:~ ~- - MEASUREMENT <br />'- PERMIT -r _• ~ <br />~.F F : :'- REDUIREMENT `L"~r ., <br />= SAMPLE • <br />.~ i= "' r=. - : MEASUREMENT <br /> PERMIT <br />:: i• ~ L J ~ - REDUIREMENT <br /> SAMPLE <br />~. E ;_ : '=':. ~ MEASUREMENT <br /> PERMIT - <br />-: " F"L 'Jr t~ ~ - REQUIREMENT - - - <br />i'~µ~ Wit- SAMPLE <br />O TAL R .~ - MEASUREMENT <br />I .. _ „ PERMIT r - L I ~ i .~ <br />", _ _ REDUIREMENT <br /> SAMPLE <br />-~ ~.... _ : MEASUREMENT <br /> s ;~ :t - <br /> PERMIT ~ <br />=K' ~ 1 .' - - REQUIREMENT ,~ _ <'~ iL.r I,.. <br /> SAMPLE ~'~ <br />_ MEASUREMENT <br /> <br />PERMIT :y ,~ ,. ..- <br />~ - <br />" . 1 , <br />.F c':_- 1 7~-:• _ REDUIREMENT ••` A V(> I. , , ~ . <br /> SAMPLE ~ ~ ~ • <br />"`_!T'Ar. F. c-.' : MEASUREMENT <br /> PERMIT [ . •t -~ -, -. +- . ; t _ . <br />-_- ~ REQUIREMENT ~ ~ - ' <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I ccrtifi under pcnalq• of low that this d~n;umcnt and all attachments wcrc TELEPHONE DATE <br /> prepsrni under my dttection or supervision in accordance with a systrn[ d~~signe[I <br />~ <br />~ L ~ <br />~ <br />" to asturc thel yualificd personnel properly gather snd evalua[r the infarrnstion _ _ <br />--` . <br />- <br />- <br />'" <br />` <br />U <br />• sttbnuncd. Bastxl on my inquiry o(the perst rt or persons who manage thz system. ~ _ ,. .. -~ ;_ ~ <br />. <br />! <br />~ <br />' <br />' <br />^ or those prrvorts direa'tly recponublc (nr gathcnng the infortnt+tion, thr informatrnn - <br />~' ~' `~~ <br />' ~ %• <br />' <br />~ <br />' <br />' <br />t <br />l <br />t <br />d b <br />li <br />f <br />d <br />F <br />l _ <br />~ ~ %' <br />' 'r _ <br />~ <br />L' <br />f_ • t !. [ <br />~ <br />~ rue, accur:ue, :[n <br />cornp <br />>~t of my know <br />edge ar[ <br />e <br />, <br />e <br />c. <br />wbn[ittcd ts, to the <br />e SIGNATURE OF PRINCIPAL EXECUTIVE " <br />- C <br /> lam aware that there a>rc significant penaluc3 forsrtbmuting falsz inf•muuon' <br />l <br />k OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED nowing eio <br />auwi• <br />including thz possibility of fine amt impnsonment (ot CODE <br />COMMENTS AND EXPLANATION OF ANV <br />(Reference all attacnmentS Here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. T I] i; i ~ ^ ~-IY,iri 1 ~ ~r;n. <br />