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PERMITTEE NAME/ADDRESS ilncfudc Facflih• NurrtG4.ocvuiun ifDij/errny <br />NAME <br />ADDRESS <br />FACIUTY <br />LOCATION - rtE <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 />NnTI=• ctaari Instrurtions hefore'•comoletinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREDUENCY <br />OF <br />NALYSIS SAMPLE <br /> <br />TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ <br />_• MEASUREMENT <br />, <br />., <br />1 ~-_, , <br />. _ - PERMIT c ."l:Iq.-r <br />_ ~ ~ L ~ ) REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />PERMIT t <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 /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFICER <br /> <br />~ - <br />~~ ~! '1~ n " ~ .crtds under penalty of law that this dinumrnt and all att.tchrncn[s were <br />~•r. p~rcd under my dvacunn or sttprn isinn m accordance with a system designed <br />u. a+wr: that yualiCu<I perscmnel properly gather end evaluate the mfnrmntion <br />subfnined. Rand on my ingwn~ of the P~'~ ur persons who rnarmge the sysum. <br /> <br />infnrmntinn <br />the information <br />th <br />( <br />ih <br />i <br />i <br />bl <br /> <br />~ ,-- . <br />~ .i <br />/ ~ - .' .r , TELEPHONE DATE <br /> <br />' . <br />rec9Jy raponst <br />e <br />nr gn <br />er <br />eg <br />e <br />or those pt:rwm d <br />submmed ts, to the b~•a of my Itnowlcdgc and t+cliet: true, aceurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - - . - .: - ~- ~ ! ~ ~-r <br />~_ ~ / ! C'"' ~~ ~ <br /> <br />TYPED'OR PRINTED 1 am aware that thcrc arc significant penalties for submitting false utfotmation. <br /> <br />incfudirg the possibditp of line and impn.onment (or rnowmg violations. <br />OFFIGER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMtN 1 A AIVU tAY1..AIVAI tvfY yr -sn ~ .w~. w~... t..~......,..... ~-...-.._-....._..-- •----~ <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />?R ECTP. EVEl~IT - SEE I. A. 1, PG. 3 FOR REQI)IREMEt <br />tii:~ ~; d 4-}iari t~~r PacF <br />~; <br />