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PERMITTEE NAME/ADDRESS rlncludeRx~ilin•.timn~~:LxanonljDr,@"e~ns! <br />NAME <br />ADDRESS ' <br />YI <br />FACILITY <br />LOCATION; ~„ , 1 ~ 4£~ <br />~,GcR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <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. 20x0-0004 <br /> <br />x <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> ~ SIS TYPE <br /> ANALY <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />_ SAMPLE <br />YC ~ , - . .. MEASUREMENT <br /> <br /> PERMIT <br />- _ ' `.; % REQUIREMENT <br />_ r SAMPLE <br />[•' MEASUREMENT <br /> <br />I '. <br />PERMIT <br />~. <br />t. - + ~ <br />-- ~~ a.. <br /> REQUIREMENT <br />!,4 :(~ ! SAMPLE <br />3~.~rr,~ MEASUREMENT <br />' +~ - <br /> PERMIT <br />;;F" i; ! 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 />NAMErTiTLE PRINCIPAL EXECUTIVE OFFICER I cerufy undn pcnalry of law that thts document and all attachnxnts were <br />en-ision in accordance with a s}~+a-m destgncd <br />ed <br />nd <br />r m <br />dtrecnon or su TELEPHONE DATE <br />~ <br />Sre7/ t' r -r.. 1,~ p <br />u <br />e <br />y <br />prepar <br />to assure that qualified personnel properly gather and e+•aluetr the inforrnntion <br />suMnittcd. E3a~cd on my inquiry of the person or perwa+ who manage the rystcm. <br />the information the in(~xrttation <br />nciblc fnr <br />atherin <br />di <br />m <br />h <br />tl <br />,l'~-~'~~ ; <br />~ g <br />ose pcrscas <br />rec <br />po <br />g <br />or t <br />y <br />xubmittcd is, to the txst of my knowledge and belief, true. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE -~,' . <br />r ~ I am aw;vc thnt them are significant prnalues for submimng false in(omtonon. THORIZED AGENT <br />O <br /> k <br />w <br />+i <br />ti <br />d i <br />i <br />f <br />l <br />li <br />f f OFFICER <br />R AU CODE NUMBER YEAR MO DAY <br />TYPED -OR PRINTED mg <br />o <br />ans. <br />mpr <br />sonment <br />ar <br />na <br />a <br />includm} the passibi <br />ty o <br />ine an <br />COMPAENTS AND EXPLANATION OF ANY VIOLATIONS (Reverence au anacnmenrs nere~ <br />I !Iii :~ .I ~-~~~rrt [t~n1~ <br />EPA Farm 3320.1 (Rev. 3/99) Previous editions may be used. PAGE GG <br />