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i_is~a;l Etc DlAME;ADDRESS ~i~:.::~... . <br />tJAME <br />ADDRESS ' '~ <br />- , -Y ROAD o5 <br />FACILITY ;::{~ fap('- <br />LOCATION)-; i t;'i 7FLY ;: D 61 b4f <br />,~~ eia . t ;~T i I A1:7T1. MTIV1= i++tANAC:~R <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) - OMB No. 2J40-0004 <br />~'' •, <br />PERMIT NUMBER DISCHARGE NUMBER )' I NAL RLiL <br />MONITORING PERIOD '-ICE i'R1=ATJ'~El~1T PL_AfJT <br />YEAR MO DAY YEAR MO DAY - <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br /> Np FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION , OF <br /> EX S TYPE <br /> ANALYSI <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE • • ._ ~ - <br /> <br />MEASUREMENT <br />- fr--- <br />~ .--, r <br /> ~ ' c ri <br />- <br />R F: PERMIT <br />REQUIREMENT ~ ... <br />., ,+ ; _ t .; i"1 <br />" I, SAMPLE - <br />T"r' MEASUREMENT <br /> t ~ - , .... :- . •~ .~ , •, <br /> PERMIT <br />REQUIREMENT '' ' t , t•.;_,' ~' T: <br /> SAMPLE <br /> MEASUREMENT <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 /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I eenih under pcmtlty of law that this document anJ all an.ldrments were <br />stem deslgncd <br />en•isioo m accordance with u s <br />di <br />ctiun <br />r su <br />d <br />d TELEPHONE DATE <br />~ i <br />r- t ' <br />i y <br />u <br />p <br />prepare <br />un <br />er my <br />rc <br />to acstlre that yualificd p~YSOmxI properly bather and rvaluute tha infortnution <br />h <br />U <br />t <br />( <br />h <br />c <br />~-_' <br />; • <br />, <br />.J ~ `- em. <br />e person ur pervms w <br />o mange <br />rc sys <br />wbmtttcd. Band on my mywr}• o <br />t <br />athering the infnmtation <br />the information <br />onsible for <br />th <br />e <br />ons dtrxtJ <br />res -y ~, _ / <br />-• <br />~ . <br />or <br />y <br />p <br />g <br />ose p <br />rs <br />submitted is. to the hest of my knowledge and belie(. true. accurate, and complete. <br />" <br />" SIGNATURE OF PRINCIPAL EXECUTIVE -- ~' , ' <:- ~ <br />~ alx information. <br />or submitting 1 <br />1 arts aware that there am significmt penalties f OR AUTHORIZED AGENT AREA <br />' violationv <br />i <br />t Ib <br />o <br />i <br />f f <br />d i <br />k <br />i <br />h <br />i <br />li OFFICER CODE NUMBER YEAR MO DAY <br />OR PRINTED <br />TYPED sonmen <br />n <br />w <br />ng <br />ine en <br />mpr <br />r <br />includ <br />ng t <br />e poss <br />bi <br />ty o <br />COMMENTS ANU tXYLANAIIVIV yr NIYT lI1VLN11V1YJ IRCIClCI/{iC OII 4{IOI.IlI11C:lIlJ IICIG/ <br />' :7R-EI) MDNTHLY F'EGARi <br />EPA Form 3320.1 (Rev. 3199) Previous editions mey be used. <br />WHETl~iE{~ AN EFFLUX <br />- 7h~~ is a d•I»n I„r~n. <br />